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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1808 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4438.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />Jos ADDRESS -i3� ly"\� -- CITYIZIP_-� mv"04\ <br />CROSS STREET_.l,O► f0 tn0�1 L _ APN i� ^ V�� O _ _ _ _ _ PARCEL SIZE R!05 +„" LAND USE APPLICATION # <br />OWNER NAMEPHONE <br />ADDRESS <br />CONTRACTOR IQft#*OA (0r0t "^rs '"G <br />CONTRACTOR ADDRESS !bol TV1f1lN j .\ Wo,, f — <br />SUBCONTRACTOR A�\E <br />CITYBTATEIZIP \\ t 7 -y <br />--- ----- PHONE -I�) 36 1 -� lo\ <br />CITYISTATEIZIP -OA , L* Qsa&" <br />_-_ _-- PHONE %frhrl <br />;TOR ADDRESS _ '`E_ ICI,T.YDI�STT�A,TTEIZIP g *'� Kn <br />I$ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dlbromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ DomesticlPrlvate D Irrigation/Agricultural ❑ Industrial Water Quality Monitoring )i Soil Sampling/Characterization <br />Public Water System <br />If differeni from Owner: !— Water System Name Contact Name or Phone Number <br />TYPE OF WQ[j Now Well ❑ Replacement Well O_ Well Atlerallon/Modification D Other <br />❑ Monitoring Well(s) # of wells Soll Boring(s) _ a of b""91 � Geotechnical u Js of borings <br />Out -Of -Service Well Out -Of -Service Well Rgnewal Cross -Connection Repair <br />Fu <br />Drilling Method D Mud Rotary Air Rotary ❑ Auger Cable Tool Push Point other <br />Proposed Well Depth 10-15 T ft Excavation 4,16 In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in dlamete <br />D Conductor Casing In diameter / Conductor Casing Depth it <br />Well Casing Diameter In Thlokness/Gauge/ASTM Sched Steel Plastic ❑ Stainless Steel Other— <br />Grout <br />ther_Grout Seal Depth ft )3 Neat Cement (04 Ib bag/3-10 gal wafer) ❑ Send Cement sack m1x!7 gal wale <br />❑ Bentonite (20% solids) Other <br />Grout Placement Method D Pumped 14 Free Fall 1$ Other Trelr•�t IT _Vi20 ❑ Retardant /Accelerator (name) <br />ED98T L Installed By O Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ODimenslons: Width ft Length _ it Thick <br />lin ❑ Christy Box O Stove Pipe <br />IpUMP ❑ Submersible❑ Turbine O Other HP Pump Set ft Standing Water Level ft <br />PIot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoluing 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 />AIININIUNI 24 110118 AIWANI'l, NOTICE RrQUIRL;D F❑It INSPECfJONS - PI.,GASE CAIA, (209) 953-7697 <br />EP„,kRTMENT SE,'ONLY <br />Application Accepted By JJAMDate Area Employee I <br />Grout Inspection By 11P Date 0 -- D SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Dale <br />Date <br />D WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />B <br />Check#/ <br />Cash <br />AmountDate <br />Remitted, <br />Permit! <br />Service Request # <br />Invoice # <br />Well IDNCodes±Info <br />2 <br />RHD043.06 I nns/202I Pae I of 2 Well I Pump Damn <br />