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1 <br /> 1 , <br /> 1b b4y5 . <br /> i <br /> 1 <br /> WELL/PUMP PERMIT <br /> SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 (209)4e8a420 b <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS [C�04''11E El 1�o Ra Do 51 -r clTy/zIP,STJCKTn►�f g51.o3 byym .V{ I161�./. <br /> CROSS STREET 4 5 0 r"0.A ST APN ) 1 y n 6 Z^ l r PARCEL SIZE 0,17• LAND Use APPLICATION N A l J <br /> `{V OWNER NAME N911110& AW'146 111 Of rhl 04'ry bF S1661 1681 "IM PHONE 2,DI-40-rip 41, <br /> Illllrrrr"_{ D <br /> YY OWNERADORES9 Z57S ( ,AND �l^ OClift bIa I.EVA66 CITYISTAYOMP <br /> $ PHONE I r L-375- 0 o,5 Ci <br /> CONTRACTOR Ma(FISL►re 6N6itJE6RIfJG j•hpFATDRIe INC• I <br /> CON tRACTOR ADDRESS 601 �1 6 F "Lr 'R Iye CITY/$TATE/zIP SAA-AA MEN"f e.1117•A( 9 5 r1 <br /> W 1 rP`, <br /> SUBCONTRACTOR lT pRILLN rNr PHONE� p y <br /> SUBCONTRACTOR ADDRE3e 1111 L76 a f'K H l LF,5 1 Y l� CITY/STATFJZW GALT LA p/ 1 S�' �7— <br /> LICENSE A C-57 0 C-61 O D-09 ❑Othef NUMBER -72-0101 ExrIRAT10N DATE L7- '7 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/COliform Bacteria(4391)0 Dibromochbropropane(4392)D Arsenic(4393) <br /> INTENDPp U3E 0 Domostic/Private ❑ Irtigation/AgriCUllural ❑Industrial 0 Water Quality Monitoring a SOP Sampling/Characterizatlon <br /> 0 Public Water System <br /> It different Irom Owner. Water SyNam ems conled Nerno or Phone Number <br /> TYPE OF WORK U NOW Well O Replacement Wei 0 Wall Allarat` -M-1lr—lines ❑Other <br /> 13Modlorvv WAS) N of watta M Soil Boring( a of bolinp td Geolechnical a of bo rings <br /> n Out-Ol-Service Well 0 Oul-Of-Service Well Renewal ❑Cross.Connection Repair <br /> 0 New Pump U Pump Roplammord 7 Pump Repair_ 0 Raise Well Casing <br /> WFt r%Z06 TRUCTION <br /> Drilling Method 0 Mud Rotary 0 Ab Rotary !Auger ❑Cable Tool 0 Push Point U Other <br /> Proposed Wall Depth 50 11 Excavation % in diameter U Open Bottom 0 Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing_ In dlameler I Conductor Casing Depth R <br /> Well Casing Diameter _in ThicknesslGauge/ASTM Schad _ ❑Steel 0 Plastic U Stainless Steel D Other <br /> Grout Seal Depth Q) R 'W Nest Cement(94)b bag/-5-10 gal Water) 0 Sand Cement sack mlxl7 gal water <br /> O Benlonile(20%solids) ❑00w <br /> Grout Placement Method M Pumped 0 Free Fall O Other 0 Retardant/Accelerator(name) <br /> o T Installed By ❑Drl6er O Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODlmanalons:Width it Length_ R Thick <br /> n U Christy Sox ❑ Stove Pipe - <br /> (PUMP U Submersible❑Turbine n Other HP Pump Sot R Blending Water Level R <br /> Plul Plan Requirements: Attach a plot plan with the enact location of water well with respect to the following items GPS <br /> Coordinatcs, property linea, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of con lamination,sewers or private disposal systems. Include distance from two property linea. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radios of proposed well. <br /> MINIVIUIO 24 HOUR ADVANCE NOTICL REQUIRED FOR INSPECPIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE,ONLY /y� ,„ <br /> Appllcallon Accepted By71 <br /> Dale In /o b I Area I 5{,t r� Jn Employee IDN /r fel Eq EIVED/ <br /> Grout Inspection By <br /> i Data I Lk 1-2 0 SPECIAL Well Permit <br /> — DEC 13Pump Inspection By Dale 0 WAIVER Received DE <br /> Soil Boring Inspection By Date Constructed Well Depth . t� uIa cou11TY <br /> EN <br /> VIRqNMENTAL <br /> C OMME NTS RTMENi <br /> PE SC - Resatvs - haekN/ --aunt ale arms Invoice N Well to# <br /> Codas Into 8 •Cash Remitted erviee ReQuest N <br /> r.IluaaloF Io�tv:o:I <br /> Writ rrum l.rr;I <br />