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ii <br /> WELL / PUMP PERMIT S'ya g <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3R FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r � > <br /> JOB ADDRESS �ra� S�"1 y�rla+�t F-d'OEC. CrrYIZIP �AV � � > � <br /> CROSS STREET X,11'1 l tm . APN I 1 (o D3 D 2-10 PARCEL SIZEe 6 LAND USE APPLICATION# � ! <br /> LA <br /> OWNER NAME /1/l"mGJr/1 "C��rr/1 PHONE <br /> gg r A O& <br /> OWNER ADDRESS 110fo '�• Oif Sc47at*4CITYISTATEIZIP Z*Ary7�yV'y1�y <br /> CONTRACTOR /tl�f� �'�7r[!lva� PHONE �+�( 49!Z 370/.� <br /> CONTRACUOR ADDRESS �Od � PI 4V,-1_Yl &J441 CITY/STATEIZIP l, e:j gra yo ^' <br /> SUBCONTRACTOR S,awtje_ PHONE G � <br /> SUBCONTRACTOR ADDRESS !' CITY/STAT <br /> ZI U 1 <br /> LICENSE 5EC-57 ❑C-61 ❑D-09 ❑Other NUMBERH MA <br /> N AT <br /> F-M E D <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y T Ran a echo <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Mo ItoriRg of amp m a <br /> 0 Public Water System Wow Dein/ co leted or insnpctpd <br /> If different from wner: ater ystem ame ontact ame or one u <br /> hV <br /> i 1 } <br /> TYPE OF WORK ❑New Well 0,Replacement ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of weils ❑Soil Boring(s) #of borings JR Geotechnical s of borings <br /> ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 0 Pump R lacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑'Air Rotary JWAuger ❑Cabie Tool ❑Push Point ❑Other <br /> Proposed Well Depth 0—/_� It Excavation & in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size in diameter <br /> ❑Conductor Casing} in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter in rJhickrtesslGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth " ft XNeat Cement(94!h bag 15-10 gal water) ❑Sand Cement sack mix 17 gal water t <br /> i <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> _ <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> B V PA T S ON A T WO N IN N SAI i <br /> JOA%l OUNTY INAN S, TE S, ND R ES AND R ULATIONS. O IF H REQ E ICENSE 1 l <br /> N rl TH LI IA ONT TORS ST SE B D A A I N AL <br /> W—WORKE COMPENS 1 WS <br /> M U DV CE NOT U D R SPECTI N <br /> SIGNED TITLE DATE <br /> tW <br /> 3 <br /> u <br /> .i <br /> 41 <br /> I L4 <br /> 1 <br /> y 71 <br /> ii � <br /> T <br /> i •A 1 <br /> i) D E P A R,T M E N T U 5 E O N L Y z H Y <br /> �IGJ <br /> Application Accepted By W- ©ate Area Employee ID# <br /> Grout Inspection By i Date ❑ SPECIAL Well Permit <br /> Pump Inspection By N Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> ,F <br /> PE SC Received ;i. Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ! ash Remitted rvice Request# , <br /> 757 7, J.-)o � a2-- a 11� S' j 3rq&q , <br /> EHD 4M2.W6 WELL PUMP PERMIT <br /> 1/27/2005 <br /> 1 <br />