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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 9$205 - (209) 468-3420 <br />I14Ut11-r%tFUNUAt5Lt t'tKMll <br />CROSS STREETI­� I <br />OWNER NAME <br />OWNER ADDRESS _ <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />UALL (LUy) yb3-(69! FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />SUBCONTRACTOR ADDRESS <br />LICENSE 1 C-57 J C-61 I I D-09 Other <br />t LL �C Crry/zIP / I U ." rr �Dju <br />0_2zzC.` PARCEL SIZE f^ 1 L LAND USE APPLICATION # <br />Q PHONE QW7 S <br />CITY/STATE/ZIP �(tcjJ//�� - U >7(I <br />P�HO�NEE20 (/"/t3i l n <br />_ CITYISTATE/ZIF��J(lr.(it / i 1 (1 / �:1�� <br />NUMBER <br />PHONE <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) DibromochloroDrooane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private [ Irrigation/Agricultural I1 Industrial I I Water Quality Monitoring C Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well 1: Replacement Well C Well Alteration/Modification Il Other <br />C Monitoring Well(s) # of wells E Soil Boring(s) # of borings I 1 Geotechnical <br /># of borings PA <br />r: Out -Of -Service W�ll E Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />L New Pump rl Pump Replacement C Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />n <br />Drilling Method I Mud Rotary I Air Rotary I I Auger I I Cable Tool I 1 Push Point Il Other <br />r <br />Proposed Well Depth ft Excavation in diameter 1) Open Bottom r Gravel Pack/Gravel Size <br />J - rnete <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />H V/ �vIN t <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I 1 Steel U Plastic t 1 Stainless Steel I Other STH DEp�4�! <br />Grout Seal Depth ft I_ Neat Cement (94 Ib bag/5-10 gal water) CI Sand Cement <br />sack mix17 gal wa <br />I: Bentonite (20% solids) [. Other <br />Grout Placement Method I I Pumped ! Free Fall 1 Other I I Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller r: Pump Contractor I I Other <br />I- Concrete Pedestal I (Dimensions: Width ft Length ft Thick <br />in C Christy Box I Stove Pipe <br />t _ <br />PUMP ` . Submersible❑ Turbine [:: Other HP�� Pump Set j � ft Standing Water Level __ALL ! ft <br />Plot Plan Req ►rernents: 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 />Mi,'r,:RlCM 24 i401 -At Ai71 ANCE N01 iCD RrQUIRED FOR I:NSPLC'i iONS-1'i_Y:ASN. CALL (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />D P RTMENT US ONLY Cj A A� <br />eqL / "( <br />Date Area 2-Z C" Employee ID# <br />Date D SPECIAL Well Permit <br />Date ql 9,1 Z :1 WAIVER Received <br />Date <br />Constructed Well Depth <br />PE SC Received Chec Amount Date Permit/ Invoice # Well ID# <br />Codes Info 13V Remitted Service Request # <br />EHD043-06 10/:5/2102I Page 1 ur 2 Wcll / Pum Permit <br />ft <br />m <br />m <br />D <br />0 <br />0 <br />X <br />m <br />