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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3RD FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> �1yS-ro�•kTas� 52a3 <br /> JOB ADDRESS `_ �E C{TYIZIP a <br /> d <br /> APN +^ 0 ~ PARCEL SIZE r t LAND USE APPLICATION# <br /> CROSS STREET ,J` ♦ VE <br /> PHONE <br /> OWNER NAME , ` <br /> y21.`S 1_{ CITYISTATEIZIP e,� I GAc q'U, - <br /> OWNERADDRESS f�� �111"^�VV�r t��(. jj <br /> f �lDrw!'C4 l��T•� ksSCX-IF�tTej PHONE <br /> CONTRACTOR 1 .( L <br /> a�j o 1 MER L+1 CITYISTATEIZIP 7�c_� <br /> CONTRACTOR ADDRESS off+-`� 1 ' /� n \ �]: <br /> Y W L-Wf4( PHONE -1 } T 7 q I o <br /> l SUBCONTRACTOR . <br /> `� F11T�^� 1{ CITYISTATEIZIP 15��� 4I`� <br />(rI SUBCON'1'RACTORADDRSSS �Ll EXPIRATION DATE 4 <br /> 4 LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 2 <br /> Illlk y Township Range Section <br /> GEOGRAPHICAL INFORMATION- Coordinates X <br /> INTENDED USE ❑Domestic/Private ElIrrigation/Agricultural ©Industrial ❑ t ual i i ,g <br /> i tion <br /> t <br /> ❑Public Water System <br /> If different from Owner: ater ystem ame ontact N me or N er <br /> TYPE OF WORK 13 New Well ❑Replacement Well ❑Well Alteration/Modification ave expire WLffidut_ <br /> gi being cdlonecteT <br /> ❑Monitoring Well(s) #of wells ❑Soil Borin (s) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal "?"MIVL1 Health Division <br /> f ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary jVAuger ❑Cable Tool ❑Push Point ❑Other <br /> i <br /> Proposed Well Depth 5b ft Excavationin diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter <br /> r <br /> 13Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 50 ft Neat Cement(94 1b bag/5-10 gal water) ❑Sand Cement sack mix 17 gai water <br /> ❑Bentonite(209/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall 10 Other E ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width It Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> �.r 1IP PREP D I TION E W JE I A <br /> COUNTY RDIN E TAT W AND LES AND CULAT[0 I SO ERTI T Y R IR LICENS <br /> C A NI CON CTORS S ENSE RD D T CO IAWITH LS COMPS AT[ LAU 24 O AD NCE NO 11 O INSPE <br /> SIGNED TITLE S1WIFf (50�:&AD&IST-' DATE <br /> t <br /> i <br /> F <br /> SOUr'NOF WAN£NOUS£5 asxs'i:rv�r uuaa <br /> �._ _145-19 <br /> Otp <br /> IV <br /> UT <br /> I \ <br /> u+ <br /> !e <br /> \. <br /> - Cl1Y OF STX'MrA✓ <br /> r <br /> a MEW <br /> l Application Accepted By Date ?/y � Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit! Invoice# Well ID# <br /> r Codes Info By Cash Remitted Service Request# - <br /> SJJIF0 r os VIM`TSL <br /> WELL PUMP PERMIT <br /> ERD 43-02-006 <br /> i 3/27/2005 <br />