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' I <br /> WELL 1 PUMP PERMIT W ll <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)9953-7697 FOR INSPECTIONS WRIQ R FROM DATE ISSUED I <br /> JOB ADDRESS <br /> a <br /> CROSS STREET r LZ C-- O _A\/X-3 APN 145-OW-0-5 PARCEL SIZE IPa Wkiat[ICy► &S# <br /> OWNER NAME i �I` �4 G7/1ZA�a�/Ayam Q� PHONE r4 676, ' 4 ✓ -y � <br /> OWNER ADDRESS aM L 1�1 _ )1 PO l�.0A 2&Z`1 o CITYISTATE/ZiP 1YTii�3/�(`��J�� q-3 I G q <br /> CONTRACTOR M1 0�+�N[I `y �i PHONE <br /> CONTRACTOR ADDRESS r° bx r!! -7 o CITYISTATEIZIP�sfibG IGT°�j 1 S Z� <br /> SUBCONTRACTOR ��G Q.'I A W RF AO --t 114 41 PHONE I - • <br /> ,^t <br /> SUBCONTRACTOR ADDRESS ,&I, W IV 14/70Ain -IIZ- CITYISTATE/ZIP <br /> LICENSE C 57 ❑C-61_ ,❑D-04 OtherAV,04't 7/ `T NUMBER PI 10. DA <br /> l <br /> GEOGRAPHICAL INFORMATION: Coordinates X F V Township RangLe-'XIdo i <br /> INTENDED USE ❑Domestic/Private ii ❑Irrigation/Agricultural ❑Industrial ❑Water Quali -40ay i <br /> d `.❑Public Water System <br /> ar" -"lf-diffdrent'frombwnn�f-7 .; -' -Water SystemN Sme <br /> TYPE OF WORK C3 New Well 0 Replacement Well 13Well Alteration/Modification 13Othe `fvllu -1, .C� �a� �t � J.L}1L <br /> f� 0 Monitoring Well(s) #of wells JWSoil Boring(s) ft of borings ❑Geotechnical ft of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> ❑New Pump 0 Pump Replacement ❑Pump Repair f <br /> WELL CONSTRUCTION II' <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ,$1 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 1 r ft Excavation� in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing ` in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in IThickness/Gauge/ASTM Schell 12Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft Meat Cement(94 1h bag/5-10 gad water) ❑Sand Cement sack mix 17 gal water <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name OW-gikft ❑Specs on File ❑Specs Submitted k <br /> Grout Placement Method mpcd W Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> r <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> Cl Concrete Pedestal Dimensions:Width ft Thick in ❑Christy Box ❑Stave Pipe ' <br /> PUMP ❑Submersible ❑Turbine ❑ HP Pump Set ft Standing Water Level ft <br /> B V PA T ON A TXBA� <br /> N IN INCE[D <br /> S, TE S, D R SAND R ULATIONRTIFY REQU 1Er1 <br /> TI TH LI IA ONT TORS STA SA IN _ANC <br /> iCE COMPENS IO WS { <br /> M H U DV CE N TI U ,p SPEC S <br /> SIGNED TITLE <br /> �.�Y " .�. DATE -U-7—=-5 <br /> l d <br /> ..y <br /> W. <br /> I <br /> li <br /> N DEPARTMENT USE ONLY <br /> Application (lGi <br /> -,� .gip �c�-�- - -�_. _ - J.- �.,. _� -.�., •_ �-'-`.__ .. _��.a - - �I <br /> Accepted By m Date Area Employee ID# d <br /> �" -,_ .❑ .SPECIAL Well Permit <br /> Grout Inspection By � � -""Date _ <br /> Pump Inspection By Date 13WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS aA&54G" W FL..,)V -r-= CoArr— S rrE - ttJdc- Ajz-� `C�/C>cnJT- 7-D <br /> [A�) <br /> PE SC Received Amount Date Permitl Invoice# Well ID# <br /> Codes Info By CIZs1h Remitted Service Request# <br /> ,I <br /> i <br /> EHD 43.62.066 w;=,Lt,PUMP PERMIT <br /> 1/27/2005 <br />