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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a FL-STOCKTON CA 95202 - (209)468-3424 <br /> NON-REFUNDABLE PERMIT E CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> elf M <br /> RE 10 <br /> CITY/ZIP D <br /> JOB ADISS — � <br /> CROSS STREET L APN O P RCEL SIZE LAND USE APPLICATION# �p <br /> OWNER NAMEIlk <br /> �� �� <br /> i { Ty Q ;. - <br /> OWNER ADDRESS /�� - L rRO nave to � W1 <br /> �} I J yy <br /> CONTRACTOR IJ T PHONE <br /> farm t, e <br /> dt- <br /> CONTRACTOR ADDRESS 302 5. <br /> k_c s •;:ATE! <br /> Crsi <br /> R II PHONE <br /> nrntvTnACT LiCen5t iF: L7!► CXPirawn Dais: _:52WJ ? .7 v U t <br /> Date: t-- , _,L! Contractor: �AUFO f la PVSg 2W6t 7Gtf•S. wc-- <br /> LICENSE ffC-57 ❑C-61 ❑D-09 ❑Other <br /> I <br /> y Township Range Section <br /> GEOGRAPHICAL INFO TION: Coordinates X <br /> [NTENDPD E S DomesticlPrivate II' ❑Irrigation/Agricultural <br /> ❑industrial C3 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water Systelmi <br /> If different from Own 11r: iter system -me <br /> intact ame or one um er <br /> i <br /> TYPE OP WORK New Well ❑;Replacement Well ❑Well AlterationfModification ❑Other #of borings <br /> #of borings ❑Geotechnical <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s)- <br /> [3 Out-Of-Service Well ❑Out-Of-Service Well Renewal ©Cross-Connection Repair <br /> CI New Pum b�Pump Replacement ❑Pump Repair ` <br /> WELL CONSTRU TC ION 11. <br /> Drilling Method 0 Mud Rotary 0.Air Rotary ❑Auger 0 Cable Tool ❑Push Point ❑Other <br /> Proposed Well DepthaO 1fft Excavation ,-_in diameter ❑Open Bottom E3'iravel Pack/Gravel Sized/4in diameter <br /> ❑Conductor Casing I in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter—4-in hThickncss/GaugeIASTM Sched /60 ❑Steel lastic ❑Stainless Steel ❑Other ✓- <br /> II ❑Sand Cement sack mix 17 gal water <br /> Grout Seal Depth_ Q/ G I.ft ❑Neat Cement(941b bag/S-lO gal water) <br /> 13 B;tonite�(200% 1lids) ❑Manufacturer Spec%solids % Name 6'5peas on File ❑Specs Submitted <br /> ,Grout Placement Method l:�'Ptlmped ❑Free Fall C7 Other ❑Retardant/Accelerator{name) Q j <br /> i <br /> PEDESTAL Installed By ❑Driller mp Contractor ❑ Other / }�( <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> - I <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> REPA T SAN S <br /> JO I COUNTY INA ES TE S, ND R ES AND R ULATION O RTI T RE E LI E <br /> CT T L I ONT CTORS ST NSE A TH 1 I OMP N WITH A <br /> WORKS COMPEN TIO AW <br /> 1 U 4 U ADV CE NOT NSPECIr T N <br /> SIGNED TITLE DATE <br /> f <br /> i <br /> fG <br /> C I <br /> f <br /> w <br /> i <br /> O U <br /> 13P, it <br /> iR <br /> � N <br /> —Ml �N . <br /> Ir � <br /> II <br /> i'. <br /> D PART T <br /> MEN _S E )DNLY <br /> Area <br /> ' Date Employee[I]# <br /> Application Accepted B <br /> Grout Inspection By Date ❑ SPECIAL Well Permit I <br /> Pump Inspection By �`� Date ❑ WAIVER Received <br /> Constructed Well Depth <br /> COMMENTS I! <br /> �G <br /> i PE SC Received hee Amount Date Permit! Invoice# Well ID# <br /> ` Codes Info By Remitted Service Request# <br /> 5A00 4 <br /> I` WELL PIMP PERMIT <br /> EHD 43-02-006 <br /> 1127/2005 II <br /> x <br />