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0 WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 7 v6_ I"t/(J a,1), CITY/ZIP <br /> /. µA�'�J� y <br /> CROSS STREET AV I� I APN 1,S`7—U 74 PARCEL SIZE �a"h AC—LAND USE APPLICATION# O <br /> OWNER NAME ( �-t�� G D So4(Q' Cqa�tAet-f),-Aej' PHONE + <br /> OWNER ADDRESS �Qt7 U( �fi CITY/STATE/ZIP r bI-0 6" <br /> CONTRACTOR !`-ri /fry, /7Yv/�`�513 �1 % ���� _.._ PHONE '2-02"f -346 ¢,..37 <br /> CONTRACTOR ADDRESS Za / Aj DL43Mf#1 tom. C]TYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> 'tea <br /> 1 <br /> QRAIT SUBCONTRACTOR ADDRESS CITY/ 1ZTP ._ <br /> jil <br /> LICENSE C-57 ❑C-61 °❑D-09 ❑Other NUMBER .6 V EXPIRATION DATE G <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Towns p Id� �angeeYpFre $ t[ OUT <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Qua%MnMFriWgYt, ]i <br /> El Public Water System bv pM' <br /> ;�nIf different from Owner: Water System Name oomo <br /> n <br /> Waith Div; <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification Test Hole ❑Other <br /> q <br /> ❑Monitoring Well(s) of wells , oil Boringp of borings <br /> Boring(s) ❑Geotechnical of borings <br /> ❑Well Destruction ❑put-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary I❑Air Rotary 1-1-1uger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter 1" <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in `Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hag/S-10 gal water) ❑Sand Cement suck mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _�-� /U(, S ❑Specs on Fite ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <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 /> I <br /> P <br /> B Y AV REPA T S ION AEAUD <br /> T WOR W O IN AN $A <br /> I S, TE S, N S AND R RTI H REQ E LICENSE j <br /> N AND ACTI WIT T LI [A ONT TORS ST THA A 1 OMP N W A <br /> E N W { <br /> H U DV C OTR SPECTI N <br /> SIGNED TITLE DATE <br /> ,1 'G PFlnSE II .I^I '--._ PNA E! <br /> eroanoe�nl.dren f' eToraae�eunura u. <br /> . I <br /> WEE, M"o� s <br /> i � 3 W ® � aroxaoi wrnr"a 7 8 � 4 i <br /> p ll � <br /> � oraruo�,BlllLgrya.s araruae e� � <br /> I <br /> I ET_vaui:;4a x <br /> • 1 - CrGAAOe EIIIf;Wi{(,'C <br /> r sea ea NN <br /> a <br /> 4. <br /> 1 SITE PLAN <br /> 1 _ ' <br /> DEPARTMENT USE ONLY �I <br />_,.,..�_-..�+rf�i" -�--v-.,�� ::=�j•- , _ ,�?+. �.�- � _ -.�_ J'3n-'�_'.... '"-_ --.w•-�-.�,�-- -"- .-- -�. _. .. - -? .v.� -•a.; <br /> / 1 <br /> Application Accepted By Date C 3 d.5 Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit fff <br /> t <br /> Pump Inspection By i Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft j <br /> COMMENTS �- 1 <br /> • I <br /> j <br /> PE Sc ReceivedCheck#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> �F3-7 2- 15a 30.o <br /> I <br /> EHD 43-02-006 " WELL PUMP PERMIT <br /> 8/6104 <br /> I <br /> j <br />