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Y <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WE13ERAVE 3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> j <br /> NON-REFUNDABLE PERMIT CALL 209 953-76!97 FOR INSPECTIONS EEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 3oq e-,t Lace-- CITY/ZIP _1 <br /> _ a <br /> +'jam{I c <br /> Ross STREET AFN PARCEL S]ZEO _LAND USE APPLICATION k 1J <br /> OWNER NAME 7/j /✓(A�- / ;y�.� ` PHONE r <br /> OWNERADDRES$ 3� Q w{�tf �V.t1�V�g CITYISTATE2ip ftk Wri an3yo Ayom� p 40 <br /> L _ <br /> CONTRACTOR WaM� {�44L P NE <br /> CONTRACTORADDRESSMk&�ArAMEU <br /> ^ <br /> SISUBCONTRACTOR1 A�Tr!i Nft -W � <br /> r. PO "4/bred withok <br /> 11 <br /> yy�� <br /> SUBCONTRACTOR ADDRESS i� . TATEfLIP <br /> LICENSE IRC-57 ❑C-61 0 D-09 13 other NUMB6r `-t <br /> GEOGRAPHICAL INFORMATION: Coordinates X ���I-+q' Y <br /> INTENDED USE ❑DomesticJPrivate ❑lrrigationlAgriculturai ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ndifferemfmm Owncn a�System ame ! Contact Nam or Phone NunibeT ^^�� <br /> TYPE OF WOR x Q New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other W <br /> a Monitoring Well(s) #of wells ❑Soil Sorin s "bangs Geotechnical k ofbanogs <br /> ❑Out-OF•Service Well ❑Out-Of-Service Well Renewal Q Cross-Connection Repair <br /> Q New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION )k <br /> Auger Method ❑Mud Rotary ❑Air Rotary 7tLAuger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth fl Excavation/ _ in diameter ❑Open Bottom ❑Gravel Pack?Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Sta le/ss�Steel J/+ ❑Other <br /> Grant Seal Depth ft Neat Cement(941b bag/5-10 gat water) Sand Cement [7'W suck mir l 7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on Filc Q Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R Length R Thick in ❑Christy Bax ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine Q Other HP Pum Set SP <br /> er el R <br /> RE H AVE P R T ICATION AN HAT THE WO WI E DR NC [TH S <br /> JOAQUI OUNTY E5, 5 L ,AND LES AND REG ATION5. 1 AL IFYQ ED CENSE 1 <br /> RE E THE FO CON CTORS STA OARD THATP NC <br /> ICE SAT] L S. <br /> TI Til It ,.TR All NC'F,NO'1"IC RI Ql`iRED 1. 'EC <br /> .,.1111D TITLE DATEI <br /> C P3 <br /> DEPARTMENT U/,;,/E O L Y <br /> pp / / <br /> Application Accepted By Date L �( Area Employee ID# <br /> Grout Inspection By Date [] SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ <br /> fnvoice� Well IDN <br /> Info B Cash Remitted Service Re nest# <br /> 0 1 0 SkoO►F 57 42 <br /> EHD 43412-006 WELL PUMPPERMIT <br /> 7fE7Rn05 <br />