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I ' WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 • (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 9537697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDREss X 13392 GRAVES RD ciTY/zIP X M AN7ECA CA 9533& <br />CROSS STREET 3 -Ac K70NERD APN 221? " OHIO' 130-000 PARCEL SIZE_LAND USE APPLICATION K <br />OWNER NAME /' RIC HOGAW - <br />OWNER ADDRESS!` 13 342 GRA <br />CONTRACTOR <br />CONTRACTOR ADDRESS 3�� S- l�- , ` r <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE V-57 C-61 :_ D-09' Other <br />PHONE P, k Hai ay J — <br />CrTY1STAT'EJZIP MAN CA Dp 9 Oji <br />PxoNtc <br />ClTYWAT8ZP'Ty -r I -a J& CA <br />P"NE <br />CITY/STATE/ZIP <br />NUMBER ` 13 I c--) X EXPIRATION DATE 5 - -t 1" <br />DOMESTIC WELL. SAMPLING: Gener2inerai/Caliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE - DomestictPrivate : irrigation/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System_ <br />If dirfereM from Owner Water System Name Contact Name or Phone Number <br />"YPE OF WORK eW Well Replacement Well ] Well Atteration/ModifiCa ion 0 Other <br />--_'_— <br />Monitoring WeA(s) _- : of Wells 0 Soil goring(s) #°rbOrl1 Geotechnical #ofborhw <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal 2 Cross -Connection. Rebar <br />New Pump __. Pumc_ Reclacement 0 Pump Repair 0 Raise Well Casing <br />WE11 CONSTRUCTION <br />Drilling Method . Mud Rotary Air Rotary 7 Auger Cable Tool Push Point Other <br />Proposed Well Depth _3(<, a t Excavation 4_ in diameter . ] Open. Bottom � Gravel Pack/Gravel Size_ in diameter <br />Conductor Casing & in diameter ! Condeietor Casing Depth _. It <br />Well Casing Diameter 10 in ThicknessiGaugelASTM Sched SO, 'g -t Steel Plastic 1 Stainless Steel Other <br />Grout Seal Dep - ,D O _ h Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack nW7 gal water <br />i entonit�e I % solids) Other <br />Grout Placement Method Pumped ❑ Free Fall D Outer _ - Retardant / Accelerator (name) <br />PEDESTAL installed By "] Driller G Pump Contractor - Other <br />Concrete Pedestal -.Dimensions: Widih _ rt Length ftThick <br />°� -- Christy Box Stove Pipe- - — <br />Eu—mp Submersible L Turbine D Other 6jP Pump Set ft Standing Water Level <br />Plot Plan Requirements: Attach A plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, propertv 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, j <br />lgriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />ii-Ni'Qt, si 24 tlOI X .>,li�:' ACL NOI ICE REQ111i'Ll-i3i OR i"+aI'Iri ilt?++� - Pi LA ih: C..ALL 13ti9) ya"3-7t'I' <br />DEPARTMENT USE ONLY <br />Applicatton Accepted By e �� Date ! 115V Area S Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Data _ WAIVER Received <br />Soil Boring Inspection By Date ^ C structed Well D9 th it <br />COMMENTS ! ea L� Pe 4J ✓ l p flP 1 ffl) )S f Ca i'�' j r t IJ r �7/l - �( i •4 <br />I� <br />mb <br />O <br />m <br />m <br />m <br />Ifs 5 34h <br />I <br />ftv I ^= wcarp„�pema <br />am r///A <br />Wwa�=MAMI WMA -1 R a 1. KIM <br />ftv I ^= wcarp„�pema <br />