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WELL / PUMP PERMIT CANNEDSAN JO i QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 FL - STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT f i` /} �� / CALL (209) 953-7697 FOR INSPECTIONS EXPIRES.1 YEAR FROM DATE ISSUED <br />JOB ADDRESS {� . `�a�a �_, _ CITY <br />/ZIP I �C��C) <br />CROSS STREET-.yV'�/`L„• APN PARCEL SIZE ! V'G LAND USE APPLICATION # <br />OWNER NAME I�S ,.,_,_,—....._... -PHONE r ❑ <br />OWNER( ADDRESS t CITY/STATE/ZIP Sze <br />CONTR CTOR 141 y I( C - LL PHONE <br />CONTRI CTORADDRESS ��y1L"u, �� _ CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 4 ExPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Ranee Cecrinn <br />INTENnED <br />USE <br />❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial <br />❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />2,TP.[10 <br />❑ Public Water System <br />If different from Owner: Water <br />ystem Name <br />Contact Name or Phone Numl3er <br />TYPE OF <br />WORK <br />❑ New Well ❑ Replacement Well p Well Aiteration/Modification ❑ Test Hale ❑ Other <br />❑ Monitoring Wells # of wells ' ❑ Soil Boring(s') <br /># of borings ❑Geotechnical Iof borings <br />Well Destruction ❑ Out -Of -Service Well <br />❑ Out -Of -Service Well Renewal <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair <br />❑ Cross -Connection Re air <br />WELL CONSTRUCTION <br />Drilling) Method <br />❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well <br />Depth ft Excavation in diameter <br />❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter <br />❑ Conductor Casing ' in diameter / Conductor Casing Depth ft <br />Well Casing <br />Grout Seal! <br />Diameter in Thickness/Gauge/ASTM Sched <br />Depth � ft ❑ Neat Cement (94 1h hug /5-10 bat water) <br />❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Qt0e . <br />rand Cement ` suck mix / 7 gal water <br />❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method r Pumped ❑ Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />Installed By ❑ Driller ❑ Pump Contractor <br />❑ Other <br />[1'EIMIEITAL <br />❑ Concrete Pedestal Dimensions: Width ft Length <br />ft Thick in ❑ Christy Box ❑ Stove. Pipe <br />P <br />❑ Submersible ❑ Turbine ❑ Other HP <br />Pump Set ft Standing Water Level ff <br />1 • • t• •'1 <br />WOMAVA <br />■■■■■■■■■■■■■■■■■■■CJ■■■■■■■■■■■■■■■■■�■MEMO <br />r!•I�■■■r■r��III■•sir...:��r.t■IIrIII■���■■■■■■■■■■i►11�■■■■■■■■ <br />MEMO <br />■■■■■■■■■■■■■ ■■!■■■■iii■■■■■■■■■■■■■�i�■■ \ ��■■■■■ <br />■■■ISE■■■■■■■■i■■■`►■■!■■■■■■■■■■■■■■iV t■ ■M■■■■■ <br />■■■fir■■■■■■■�l■■■■'■M�i►q■■■■■E■■■■■■■■i■ O■■■MEN <br />■■■■■■■■■■EMI■■■■i�■D■■■■�'rZ� ��r. <br />■■■E■■■■■■■■EIS■■■M!�■■�r■�e■■■■■■■■®■L'L�J■�' '■�r■■■■ <br />■■■1■�■■■■■■■I ��rr■ASE■.■■Niii!■I•��w+IA■■■ <br />CA <br />UP - <br />5 <br />PE SC Receivedh <br />Codes Info B <br />Cash <br />Amount Date Permit/ C nvoice# / WeiI1D# <br />Remitted Service Re uest # <br />`•f3.1 f ICS- <br />2,TP.[10 <br />EJ -ID 41-02-006 WELL PUMP PERMIT <br />#/W04 <br />�a <br />