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L+ws-s5� <br /> 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 I YEAR FROM DATE ISSUED <br /> E JOB ADDRESS T�3� ��T�I1 1��C CITYIZIP 1.5TOL��00 ci's _ 9 <br /> 7 <br /> CROSS STREET SL. APN PARCEL SIZE `� LAND USE APPLICATION# <br /> OWNER NAME iLt3T SLt>P i- a\_*Atw o,F- PHONE <br /> OWNERADDRESS �3Z PLy OLn-c�t _ CITYISTATEIZIP TOC�cTo� �' ' aS2� <br /> S <br /> CONTRACTOR I U L�13 D PHONE 3 ism -N7 ON <br /> CONTRACTOR ADDRESS CTTYISTATFJZIP VlDbli CA !95 2AP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZiP <br /> LICENSE C-57 [3C 61. 13D-09 ❑Other NUMBER q c- TI N D TE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y ` Townshtp RaWn <br /> ct o <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial M Water Qua�i��i�i Er y h iupIR � �ian <br /> ❑Public Water System N <br /> Vdifferent from Owner: Water System Name ainspected <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Weil Aiteration/Modification 00twLiilylrorml tt1 Health Division <br /> Q Monitoring Well(s) #of wells .cv�rSoil Boring(s) /� a ofborings ❑Geotechnical #ofborings <br /> ��1a <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump O Pum Replacement 13 Pump Repair <br /> WELL CONSTRUCTION <br /> i <br /> Drilling Method ❑Mud Rotary ❑Air Rotary )Auger 13Cable Tool ❑Push Point ❑Other 00l0 <br /> Proposed Well Depth ©—1 ft Excavation _-in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter N <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ft ^ <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other W <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water Qo <br /> 3Atk JrILL. fol+— 7r r~ Gs <br /> ,�entonite(20%solids) ❑Manufacturer Spec%solids % Name rC , Cf,6# <br /> Fe on File ❑Specs Submitted 04 <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> EPEDESTAL Installed By ❑Driller ❑Pump Contractor they <br /> 13 Concrete Pedestal Dimensions:Width Length ft Thick in 13 Christy Bax ❑Stove Pipe <br /> h PUMP 13 Submersible 13 Turbine ❑Other HP Pum t ft Standing Water Level ft <br /> i <br /> I ♦ ". D I TION T E W D EPVRE�k <br /> RDAT-AND LES AND GULAT10 S ERTI T AR D LICENS S <br /> AC A N CON CTORSS ENSE ARD I MIA1 H L <br /> PE AT[ LAO AD NCE NO RE O INSPEC O <br /> SIGNED TITLE ✓ `' DATE 'd <br /> k = _ <br /> RECEIVED <br /> 13k. <br /> I _ 116 CA44 <br /> _a—R •r —�E15� eAft 1�o OCT, 13 2005 - <br /> R x ; <br /> L14 113 SAN JOAQUIN COUNTY <br /> ` <br /> ENVIRONMENTAL <br /> o y 0 =x .._. v nN 59 13IYEfi HEALT E <br /> i h 4 � ten'.sa ®�, �• a �12��z <br /> O <br /> b <br /> 20 <br /> W , 8.47AC. <br /> j �- sm�w aura nc m°smc A <br /> 14 <br /> e 13 - DR r $ 32 <br /> Dlc't ¢ <br /> Rt 15 k <br /> i <br /> ai D AN AVE, <br /> FFF 3 O <br /> �+ - —-- - -—1 _1 I F71-1-1 4 — - ---.— TTTT <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By Date l Area Employee ID# <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIvER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> k� <br /> PE SC Received Check#1 Date Amount Permit/ <br /> Invoice# WellID# <br /> Codes Info B ash Remitted Service Request# <br /> -? ISO G- 9(>,-Q 0 DS S�oaU�35 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> W7f2005 ' <br />