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14 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS OI 7 At <br />CITY/ZIP <br />tjo� S <br />CROSS STREET (P <br />/ <br />APN 6 d q 0 q �� tJ PARCEL SIZE • �p <br />- <br />LAND USE APPLICATION #Q <br />Dkal/� <br />OWNER NAME C�1 S <br />7i6 <br />y <br />C(?--? /c� <br />OWNER ADDRESS <br />7 ' CITY/STATE/ZIP <br />lPPHH,O�N�EO?/f(ty�� <br />a* /ir! % 5al J <br />CONTRACTOR <br />20? D <br />PHONEr�,,,, <br />n <br />CONTRACTOR ADDRESS PV <br />CrrYISTATE/Z1P_ 56at <br />Q�-- <br />/'� o4 7G✓�`S <br />SUBCONTRACTOR <br />PHONE 4-4 <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 ❑ C-61 ❑ D-09 <br />TAATTE/ZIP <br />❑ Other NUMBER U [ <br />/� <br />EXPIRATION DATE /C-7-93 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />1 YPE OF WORK U New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pum 9.Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pine <br />PUMP A Submersible❑ Turbine ❑ Other HP -/7- Z Pump Set / ft Standing Water Level <br />Plot Plan Regnirements: 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 />\HN-1`Hf 1 31 iit_1t-f, ADVANCE \UIICE REQ( lRED FOR INSPEC-1 ii %:tic_ PLE:1,S (209) 9=_-76'1' <br />Application Accepted By <br />,:n-- jz- L- L, <br />DEPARTMENT USE ONLY <br />Date r- 1. .! <br />Grout Inspection By Date <br />Pump Inspection By / l _ v+- Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />OEM <br />Area q � �� Emplop,�fe, <br />❑ SPECIAL Well P!V- <br />❑ WAIVER Received Nr <br />Constructed Well Depth IUAI # oft <br />L �r SAA, . <br />_0 <br />D <br />PE <br />Codes <br />SC Received Chec I Amount Date Permit/ Invoice # FA ID <br />Info B sh Remitted I Service a ues # <br />L 3 g) <br />:i <br />PapI of 2 Well / Pump Permit <br />