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(� WELL/PUMP PERMIT <br /> SAN <br /> _y.y IN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT _ _ CALL 209 953-7697_ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS i�}qidv�er .�i.ldv�CITY/ZIP <br /> rn <br /> m <br /> 1,' /► n tI D <br /> CROSS STREET UJ I APN L2�q -50'4� PARCEL SIZE 10,61 LAND USE APPLICATION# A <br /> OWNER NAME CT/-/ �� a-/1 L fF.� PHONE y <br /> w . <br /> OWNER ADDRESS IrR'h'7 e— CITY/STATE/ZIP <br /> CONTRACTOR <br /> - T <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ? LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> t' <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria (4391)7�Dibromochloropropane (4392) rsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification Other a G s <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical }�#of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 1�A <br /> ❑ �/lq,� <br /> New Pump ❑ PumpReplacement ❑ PumpRepair ❑ Raise Well Casing <br /> WELL CONSTRUCTION ALZ /Jvpn <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size_ )ameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft SSA/l/J 4 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless StAelEI /td <br /> Grout Seal Depth ft ❑ Neat Cement(94lb bag/5-10 gal water) ❑ Sand Cement GG�4LrN n a ater <br /> ❑ Bentonite(20%solids) ❑ Other AR �1V3'— <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> :%IINI 11C';N1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> EPARTMENT US <br /> ONLY [1 p <br /> Application Accepted By C am' Date / ' 3/Z Area 7 /�� Employee ID# ~ �" <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS f- ZQM6jnAQIA�u <br /> v <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Ca h Remitted Date I'Aarvice Re uest# Invoice# Well ID# <br /> 11 <br /> EHIM3-06 04107n022 2 , Pa� o <br /> Cu� p Vdl/Prrk�Pac <br />