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t <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> b F, <br /> JOB ADDRESS 1.J OU t ! • " CITY/ZIP <br /> CROSS STREET& APNPARCEL SIZE 0.06 aCLAND USE APPLLI/C/ATION##/ / Y <br /> OWNER NAME /KECZPj0A I34tile1+l. PHONE 7110 iL��� '{7�,Q <br /> OWNER ADDRESS /-f 2A6 jo&-t"Al (3(,VO- 1 /41) CITY/STATFJZIP CsAAAJ, F- 64( cA 7.-2% <br /> CONTRACTOR A)E'rI_ C). A JQ A4SQt—t.47'E r PHONE Loq -3to-4-- 34o ( <br /> CONTRACTOR ADDRESS q0-2� =./0041S?`pAL L!/ Y CITY/STATE/ZIP L449-T l{SLLfU <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE K-57 ❑C-61 ❑D-09 ❑Other NUMBER tp Li EXPIRATION DATE i <br /> I <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultuml ❑industrial ❑Water Quality Monitoring `Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num r <br /> TYPE OF WORK ❑New Well ❑Replacement We]] ❑Well Alteration/ModificationQth + <br /> 13 Monitoring Well(s) #of wells W'Soil Boring(s)� # /borings eot a I I I kol—b-ILK" <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal O <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair it*' nQexpired without ithout <br /> WELL CONSTRUCTION worK being completedor inspected <br /> Drilling Method 13 Mud Rotary 13 Air Rotary ;kAuger CI Cable Too] shRm0ron FROtlea! NA ' iOR <br /> Proposed Well Depth 40 w is:ft Excavation (Q diameter ❑Open Bottom ❑Gravel Pack)Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R t <br /> Well Casing Diameter in ThickncWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Sea[ Depth ft ❑Neat Cement(94 th hag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name S0;l (. #+- ha 3 ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 64Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> I <br /> PEDESTAL Installed By Pu p o ctor C7' Ot <br /> ❑Concrete Pedestal Dimensi2 th ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑ e ''1?' Pump Set ft Standing Water Level ft <br /> B V PA T Mill ON A WORPSP <br /> NIsRelll). <br /> NC �A <br /> JOA IN OUNTY O INAN S, TE S, D RU ES AND RE LATIONXD <br /> CHM I <br /> C N Ti H LIF IA NT :TORS STA SANL <br /> NS WS. <br /> Y <br /> H U DV ICE NOTE UI {/SIGNED TITLE F 91210(b + <br /> F_�•1�,z..►�ert DATE <br /> C 4 <br /> p 4 <br /> �r�E <br /> 7t 1 <br /> SA 44 `j V <br /> -. x E N R N 0 T <br /> ,� <br /> - .. ._ D AR MENT US <br /> Application Accepted By�fa!/l J�L ]NV\ \ Date Area Employee lD#� � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received eck#! Amount Permit/ <br /> Codes Into - ash emitted Dat Service Request# Invoice# Well ID# <br /> a g <br /> END43-02-006 WELL PUMP PERMIT 3 <br /> 1/27/2005 <br />