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103o'tI 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT SC Received Info B GALL (209) 953-7697 FOR INSPECTIONS tXPIKtb 7 YEAR FROM ISSUED JOB ADDRESS 151 51 E. G-�e,IA /U_ATE CITY/ZIP Riad t CA �S3UU �p CROSS STREET /� t;y {J LJ APIN U f�S 1 r� `� r�' PARCEL SIZE �P LAND USE APPLLIICATITIONG# L114 OWNER NAME Ro,"i", 1��• `' �S .� tQ�-S p PHONE 209. ICA- • (D C 7 1 OWNER ADDRESS 13L) Aje-I CITY/STATE/ZIP t2t�on I t'^ 953(,(0 CONTRACTOR VaA GI0`�v"'• 6"-0 ,6,nT ,y., 'jam 1.✓✓1 �I(n.11O'A J-YkC- PHONE 20 . II j r (PZ CONTRACTOR ADDRESS C) S •tJ -•IGGk I UKG IQd CITY/STATE/ZIP m,&+e LA CA ?6.33Cv SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE G C-57 )( C-61 t I D-09 ❑ Other PHONE CITY/STATEIZIP NUMBER 1Dy Z l ! ID EXPIRATION DATE 2131 J ZDZZ- DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE 11 Domestic/Private X Irrigation/Agricultural L. Industrial 1.1 Public Water System If different from Owner: Water System Name ❑ Water Quality Monitoring 1, Soil Sampling/Characterization Contact Name or Phone Number TYPE OF WORK ; New Well I Replacement Well Well Alteration/Modification I I Other - Monitoring Well(s) # of wells -Soil Boringq of boringss) '" Geotechnical Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair A New Pump I i Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary Air Rotary I I Auger I Cable Tool _1 Push Point I Other Proposed Well Depth ft Excavation in diameter f1 Open Bottom Gravel Pack/Gravel ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic I I Stainless Steel Grout Seal Depth ft I) Neat Cement (94 Ib bag/5-10 gal water) IJ Sand Cement 1 Bentonite (20% solids) l� Other Grout Placement Method i Pumped ❑ Free Fall C Other Retardant / Accelerator (name) #oftl r�ij�C6"V, Nr PA n _ Sq N Epq R MF T Y Other _sack mix/7 gal water PEDESTAL Installed By ! 1 Driller % Pump Contractor !.1 Other l }(Concrete Pedestal ❑Dimensions: Width 4 ft Length ft Thick in Christy Box ❑ Stove Pipe PUMP )(Submersible Ll Turbine 11 Other HP__L!�j_ Pump Set /00 • ft Standing Water Level s Z ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS Coordinr:tes, 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. MINIMUM 24 110UR ADVANCE NOTICE, REQUIRED I,OR INSPECTIONS - PLEASE CALL (209) v-3-7607 Application Accepted By `—;70 L Grout Inspection By Pump Inspection By Soil Boring Inspection By 0MENITS N , vJ ,�J10 11 Cf I'rn'(I DEPARTMENT USE ONLY Date Jd"2";2 3 Date Date Dale Area i' C" Employee ID# n (_7 ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes SC Received Info B Check#/ Amount Permit/ Cash Remitted Date Service Request # Invoice # Well ID# N 3 YO E I ID043-06 M25 2011 PaEc I or 2