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WELL / PUMP PERMIT r9'0)- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 300E WLBER AVL 3ktl FL - STOCKTON CA 41i= - (?nm AAM -111A <br />NUJN-REFUNDABLE PERMIT �!' CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 12�J fr i M�( '� /� CrrY/ZIP / $;T /"d+ % �� r1? <br />CROSSSTREET ����^��"�APN L%�•���Qf, PARCEL SIZE_ Cf ..Y 5s" <br />OWNER NAME' <br />GIMP—A-77 PRONF114 -- <br />OWNERADDRM JZ ¢bfi L . j'y /ta �A j / CITVISf•ATE/ZIP �d� <br />CONTRACTOR tor,) V D+ A r•f /J b7L�J,f ,Q. C, <yG . PHONE 7 - -j -7 /1!1 - <br />CONTRACTOR ADDRESS _ -LZ �a O -r S 7'4�Af GI . CITV/SPATEIZIP 4,!5!!0 7 q 5-- <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS /ty C1TV/STATE/ZfP <br />LICENSE C-57 ❑ C-61 ❑ D-09 13Other ' NUMBER EXPIRATION DATE-,6- <br />GEOGRAPHICAL <br />ATE GEOGRAPHICAL INFORMATION: Coordinate, X V T—..hi. o.,.... <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />[Fdimercnr from Owner. ager ysrem arnc onu,n amen one u er <br />-.-•• - n a r.ncruuummoemcagon u fest Hole LIOther <br />11 Geotechnical ❑ Ivlonitoring Wells number Of"Soil Boring(s) 4 number of borings number of Wangs <br />.�[_. <br />D Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />Li New Iump U Pump Replacement ❑ Pump Repair <br />❑ Cross -Connection Repair <br />WELL CONSTRUCTION <br />Jia Ii[�Lr�����yla!•�I <br />Drilling Method ❑ Mud Rotary- E3Air Rotary l .Auger O Cable Trial 13Push Point 13 Other <br />Proposed W 15 <br />Well Depth � ft Excavation(_ in diameter <br />❑ Open Bottom ❑ Gravel Pack/ Grovel Size in diameter <br />D Conductor Lacing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schell <br />❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depthraf/ g4lnl ft ❑ Neat Cement (94 It, hag /5-10 gut water) <br />11 Sand Cement sack Mir t 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % <br />Name 3 �1/ ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By O Drille 1u Contractor <br />❑ Other <br />D Concrete Pedestal Dime ons: f ft Length <br />ft Thick in ❑ Christy Box D Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP <br />Pump Set It Standing Water Level R <br />WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased <br />❑ Other <br />Well Diameter in Total Depth ft Depth to Water <br />ft ❑ Casing to be Perfor to from R to R <br />Sealing Material ❑ Neat Cement (94 Ib bag /5-/0gat water) Q Sand Cement <br />sackm& / 7 gal water Bentonite Pellets <br />❑ Bentonite (201/. solids) ❑ Manufacturer Spec % solids —% <br />Name Specs on File D Specs Submitted <br />Placement Method ❑ Pumped D Free Fall ❑ Other <br />❑ Complete with Mushroom Cap ft below grade <br />D Complete to Existing Surface Pad <br />1 I •r ••a 11 a•1 <br />a ♦ 1 <br />s • 1 1 ' 1 1. <br />L/ 1 A• <br />WOMEN===no <br />no 11 <br />■G1■01■1■■■■■■■■■0101r I <br />■■1M0101■■■■■110101/01 11 <br />ERNM■i■■■WMA E■■ren■■ <br />BENUEi■rllMlsM. 11//mIi01In <br />MEMO ME ENNEWMENA <br />NEWS 11111111MMONN11 <br />�0101ti 1010101■■010111FAREE 01 <br />�01■Y�I■■■■■■■0111■■//1111 <br />O <br />A <br />F <br />171 <br />— <br />Application Accepted By Date 7i A Area ` Employee IDtFff , <br />Grout Inspection By PAYMENiiate ❑ SPECIAL Well Permit <br />Pump spectionB E 'e / ❑ WAIVERReceived <br />Destruction speatio ,Y Dat J a/ ��� - Constructed Welt Depth ft <br />COMM ENCS / <br />12/612002 <br />Jia Ii[�Lr�����yla!•�I <br />iT•!J/ � � +./ � %�/vl��� <br />12/612002 <br />