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1 WEL PUMP PERMIT) SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AST HAZELTON AVENUE - STOCKTON CA 96206 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR IN SP JOB ADDRESS a \ -vs-13 ."\,-.3.,-.6,3v- --(\ 6, CITY/ZIP L C' Cfrk" Ck 9 0 r CROSS STREET .-\ -e.VVISZV-C1/47.S '-?•4:S APN OS -3- 27445-0 I PARCEL SIZE° 3 e LAND USE APPLICATION # OWNER NAME c-3, 'S-)V-1\ e-Ci-k^- rC 0 \'‘\ C.-\ CZ1,-C t PHONE .2(A I OWNER ADDRESS „.7Q'D-.Ct.. 0 '-'C'43...v\.6</C-- lqt•-...6..., CITY/STATE/ZIP Lepa..\ CF RS----1---ko CONTRACTOR —k-NrArN.. C!is:-\\---1-0‘1\ '..1:Z-SkTik .4c- Q/5 LkS \--"Ct-0-4-.N-.•. 0 tA, PHONE 'Q. cYz\. qTA- '-t a,c%-- CONTRACTOR ADDRESS 'CD. f-r ,"cn)( 1-6 S.-5s' CITY/STATE/ZIP \-421••• 1-.\\-9.2c-scza\--\. 6'3 )cA ckS3 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE Li C-57 D C-61 Ti 0-09 [1 Other NUMBER t (253 L\ cisigs.. EXPIRATION DATE DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) INTENDED USE D Domestic/Private AI Irrigation/Agricultural 0 Industrial 0 Water Quality Monitorin [7 Soil Sa pling/Characterization 0 Public Water System S cf. \0-'r- 1--- kl R. 'Viz) c\<. - ,r- c.D If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 0 New Well IA Replacement Well LI Well Alteration/Modification 0 Other CI Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 11 Geotechnical #01 borings El Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair cc- )5.New Pump 0 Pump Replacement L:1 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION . Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool D Push Point - !* Other _ Proposed Well Depth 2 _ft Excavation in diameter D Open Bottom CI Gravel Pack/Gravel Size in diameter Li Condurfor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter ' in Thickness/Gauge/ASTM Sched •_ 0 Steel ; :IPlastic CI Stainless Steel E Other Grout Seal Depth _ft [1 Neat Cement (94 lb bag/5-10 -ta/ water) 1-1 Sand Cement sack rfilkNa ENT t . 'Bentonite (20% solids) Other (. -\ RECEIVED Grout Placement Method 0 PuMped D Free Fall FI Other 0 Retardant / Accelerator (name) igfAlrrtr9 PEDESTAL Installed By 0 Driller i4Pump Contractor 0 Other -it Concrete Pedestal 0Dimensions: Width kf ft Length `•••( ft Thick , l t ' AN JOAQUIN COUNT , in 0 Christy Box 0 Stove Pipe ENVIIRONMI7N int .1-rAl Ili DEPARTME4 ELJE.AE RV V) CI Submersible El Turbine Xl" OtherGru,vta-0$ HPll5ci‘. GKPump Set ft Standing Water Level LI V ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. DEPARTMENT USE ONLY ,.... Application Accepted By - --- /-1--- Date 3 /2(//),,2 Area IV 6% (/' Employee ID# r (r1 i ' ( Grout Inspection By n Date 0 SPECIAL Well Permit Pump Inspection By / 'LL,---.4.-- Date 4-1 t -z_ 0 WAIVER Received ' Soil Boring Inspeition By Date Constructed Well Depth ft COMMENTS tJell Fyfrylit- WPOC3cfei/ PE Codes SC Info i Received Checkit/ t Cash Amount Remitted . Date Permit/ Service eAvet # Invoice # Well ID# OS-/ h)V , / 127- LC (1 1 47)1' 1, C/) 7:r rTl 0 ci 1 c t-41-e str a2 3121-,31 A71-- 5101)043-06 1012512021 Well / Pump Permit