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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />14lUI4-KEFUNDABLE PERMIT CALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 1 71 1 R Fight Mile Rd CrrYlZIP Stockton, CA 95212 <br />CROSS STREET St Rt Hwy 88 APN 06312004 PARCEL SIZEJ2_Q__7_6AND USE APPLICATION # <br />OWNER NAME Cooper Blit WP -t* Tnr, PHONE 209 601 5876 <br />OWNER ADDRESS P -0 -Box 22f; CITY/STATE17iP L i ri Pn , CA 95 �'IA <br />CONTRACTOR Purvi aneP Dri 1 1 Pr--, r Tnrr PHONE 209 887 3554 <br />ADDRESS—P n R -X 64 CiTY/STATE/ZIP L i n d e n r(' A 9 5 2 3 A <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE Ik C-57 ❑ C-61 ❑ D-09 0 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER -7 7 9 2 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392) : ; Arsenic (4393) <br />INTENDED USEDomesticJPrivate 0 Irrigation/Agricultural ❑ Industrial Ci 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 0 Other <br />"I <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical <br />ivsm 1 ,c <br />VEe <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />SAN JO ?Z <br />Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />A <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />LT UN r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />R T/SEN <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length ftThick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP ` Pump Set ` �J ft Standing Water Level <>' it <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 />�il`.t111 NI 24 iiOl i> i},, <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By 41 Date <br />Pump Inspection By / i r✓ Date '�' Zz <br />Soil Boring Inspection By Date <br />Area ll C1�' Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />�2 <br />PE SC Received <br />Codes Info <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD043-0610/25/Ml (')W. <br />' / / �I' J -2 [ rso7 Page I of 2 Well /Pump Perron <br />