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job WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3410 <br /> NON-REFUNDABLE PERMIT I�. CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J08ADDRE55 E +�t t� ! _Ld+Tl "243_ -01,a l_p�� CITY/ZIP L4,4l�lt-ee 15-334 9 <br /> 7476_Mw s,o d <br /> C CROSS STREET lyGLl�! C��I�il�n ►VIt,APN Z{7�-7.�0��Z PARCEL SIZE LAND IISE APPLICATION# tz <br /> OWNER NAME R:ver =r�.lA%Adl S7,z 74,E —0 f� PHONE <br /> r <br /> OWNER ADDRESS J S. I� CITYISTATEIZIP Let f h,.p CA/ 95330 <br /> CONTRACTOR I`IP7 C PHONE�JyD g ] 3 S—d6�O- " <br /> CONTRACTOR ADDRESS no dF CITYISTATEIZIP C <br /> SUBCONTRACTOR fRCI C-CC Dt-i �i t✓L�s PHONE <br /> i <br />' SUBCONTRACTOR ADDRESS I-L 1 .708 SQr, PA b(t% &e- CIIT(�Y//STAATEIZIP -Yt TQSe1 cm f�/IG7 <br /> LICENSE C 1311 - <br /> -57 C-61 i M D-09 ❑Other NUMBER 144 3.9 1 --_ r06 <br />' JMr <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> r <br /> INTENDED USE ❑Domestic/Private t ❑Irrigation/Agricultural 13 Industrial ❑Wa o to l li g/,_ tion <br /> a <br /> ❑Public Water Sstem <br /> t Hdifferent from Owner: Water System Name ., t t a e or one r - <br /> �I. <br /> TYPE OF WORK ❑New Well []Replacement Well ❑Well AlterationlModification q-"N ' may se <br /> f° #ofborings v gs <br /> ❑Monitoring Wells) #of wells (Soil Boring(s) �Q-7%0 o h tca <br /> �, �,�� O at ins ected <br /> ❑Well Destluctionj� � ❑Out-Of-Service Well ut- ery e <br /> O New Pum ❑PumpRe lacement Q Pum Re air oss''2 Re'` Health Division <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary KAuger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth P Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Well Casing Diameter ins ThickneWGau e/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft„ Neat Cement(94!h hug 1 S-10gal water) ❑Sand Cement sack mix/7 gal water C, <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted C_ <br /> Grout Placement Method ❑Pumped J1 Free Fall XOther 'CC-bvh:@d ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 11! ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove:Pipe <br /> PUMP ❑Submersible 11 ❑Turbine ❑Other ' HP Pump Set ft Standing Water Level ft <br /> RE FY HA` PREPA ITNO <br /> TION WQ AO I DAN S <br /> JO UI COUNTY DIN E ATE AND O I OFNS <br /> T T R E <br /> Cu AND AC E WI T ALI NIRS ST E LICENSE D 1 I COMP AN WITH A <br /> K EN AW <br /> k 4 E E REQ E O 'T N <br /> SIGNED TITLE Cl I DATE <br /> \\ <br /> WA <br /> 16L <br /> i it I =- <br /> 1l-�� r <br /> f+- <br /> yi <br /> j =:mom fit. u , ;- <br /> f "" r <br /> � 'o` eP&` �'"m-�� <br /> i <br /> aklm <br /> ' r `DEPARTMENT USE ONLY <br /> Application Accepted By "i Date <br /> dS Area Employee lD# �; S <br /> Grout Inspection By I`I Date 11 SPECIALWell Permit <br /> Pump Inspection By �`` Date 11 WAIVER Received <br /> Destruction Inspection By I`I. Date Constructed Well Depth ft <br /> COMMENTS �! <br /> J� <br /> .i. <br /> PE SC Received �� (Check# Amount Date Permitl Invoice# WellID# <br /> Codes Info B as Remitted Service Request# <br /> 7ZS X30.WJ 10 �-) "Z) L4 {3 1 j - <br /> + EHD 43-02-006 �P,'.. •� r' �`�T4' (���" `[�'`�� WELL PUMP PERMIT <br /> ` 576104 <br />