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a`p 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ "I I� DA&9 CITY/ZIP <br /> a <br /> CROSS STREET O \ C-4eAPN It - 2-90:Q PARCEL SIZE r �� <br /> J✓ e-` LAND USE APPLICATION#r, <br /> C.(' Liu-Cl-6N .� PHONE/5-0c, <br /> OWNER NAME r`� ^y�� u /� /� <br /> OWNER ADDRESS if ij T• I1 �1yO�'�7�� (G*�• CITY/STATE/ZIP ��1J�ST7) - <br /> 1 I� PHONE 7-f -7 3� - <br /> CONTRACTOR �, <br /> � b-1� �. tq-1�IQ�\�Jb�J � f}:SSc'�[��-!}'1��_ iLo.-1- <br /> ii��-+�� <br /> CONTRACTOR ADDRESS <br /> �yZ '�(.�tAS l iR3:.�2.. 1. .. CITYISTATEIZIP _ <br /> SUBCONTRACTOR I� PHONE <br /> SUBCONTRACTOR ADDRESS I� CITYISTATEIZIP <br /> LICENSE kC-57 ❑C 61 ❑D-09 ❑Other NUMBER 00q EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/private ❑IrrigationlAgricuitural ❑Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water Sys �j <br /> stem 4—, <br /> i If different from Owner. Water System Name ontact Name or one Number <br /> TYPE OF WORK ❑New Well I��❑Replacement Well ❑Well Alteration/ModificationP1 <br /> [3Monitoring Well(s) #of wells )9L5oil Boring(s) oM.n , G n i a os r' gs C <br /> ❑put-Of-Service Of <br /> t <br /> ❑O <br /> Well u- -Service e <br /> F Wll Renewal Pr I�91V7t h5WVa 6Xplred WIthOLJt <br /> ❑New Pum 1!❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION Ii worK being completed or Inspected <br /> Drilling Method ❑Mud Rotary 1❑Air Rotary .Auger ❑Cable Tooljqh t.7Wfth- .}O�_ <br /> b�'�u1���151J1 lmeRea <br /> Proposed Well Depth lM ft Excavationin diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter i`n Thickness/GaugeIASTM Schell El steel ❑Plastic [3 Stainless Steel ❑Other <br /> Grout Seal Depth iI ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%�solids) 13 Manufacturer Spec%solids % Name C_-,of I Carl i-i•� S ❑Specs on Fiie El Specs Submitted <br /> Grout Placement Method ❑Pumped Free Fall 13 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By [I Driller ❑Pump Contractor ❑ t <br /> r <br /> ❑Concrete Pedestal Dimensions:Width gt ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible 17 Turbine ❑Other Pump Set ft Standing Water Level ft <br /> •ERS-_-rff ...._ [ H/ ; PREP ED 'H_-FA <br /> TION E W K D E <br /> J Q N COUNT) ORDIN, vCl i, STAT' AR ANAND EGULATIO L CERT A Y R 1FDLICE11, SCSA( '"" " .fH H. CA' II 1 COORS ENS ARD D T M I <br /> OR RS COMP SAT►'N LA' S. <br /> LA LES <br /> H R AE N (('�C' SIRE. FC t INSPEC 10 S rJ+' r F NE DATE SIGNED TITLE <br /> I <br /> .o <br /> h W;7 <br /> aI <br /> M 'A <br /> M <br /> At AA U1 <br /> ED'! <br /> NA <br /> DEPARTMENT USE ONLY <br /> I <br /> Application Accepted By Date - O(o Area Employee ID# <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ij Date ❑ WAIVER Received <br /> Constructed Well De th a ft <br /> Qi, '� ,s �rt�e,,,t �rE� .YJ�tc l��tC� ✓i c T`Z- <br /> ' COMMENTS_ d �3 ✓ <br /> T :h <br /> PE SC Received (4CIi�ecl�!Iy Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ,w _--eish Remitted Service Request# <br /> 4-372 1'50 S 0 C1 520 <br /> �I <br /> EHD 43.62-D06 WELL PUMP PERMIT <br /> ' -� <br /> ? 1127!2005 <br />