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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />(JOB ADDRESS c7 2210 Mi nkf Lide _ CITYIZIP a of 0- — - -- <br />CROSS STREETI "'f APN12$Q 3QIi2, PARCEL SIZE$,32ULiiAND USE APPLICATION # <br />� y- U tU030Q4 S•13 <br />OWNER NAME <br />L. <br />1 (] r-� ��,,,"�,Q,,�" �_.. rQyt�, • �,�GQ•r �, "_ - PHONE�y� 1,. <br />OWNER ADDRESS C . 1^TPM"r g+. I �0� � M CITYISTATE/ZIP_���l�rtr < �a-AItg1 �T "Lfa <br />CONTRACTOR �i';1 j V• 4-rapi by l - A-rocya(imLiMAQ.h PHONE <br />CONTRACTOR ADDRESS oij 'riw V _ CITY/STATEIZIP �Qd <br />I � <br />SUBCONTRACTOR-)C�rcQ 0,6 OWlife _ _ _ PHONE CLS 0601SUBCONTRACTOR ADDRESS tj/Pr CITYISTATE(ZIP ill <br />(LICENSE VC -57 <br />❑ C$1 ❑ D-09 ❑ Other NUMBER <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE <br />- Domestic/Private D Irrigation/Agricultural 0 Industrial C Water Quality Monitoring A Soil Sampling/Characterization <br />C Public Water System _ _ _ _ _ <br />__ <br />If different from Owner. Water System Name Contact Noma or Phone Number <br />TYPE OF -WORK <br />New Well ' Replacement Well 0 Well Alteration/Modification -1 Other <br />C Monitoring Well(s) _ # of wells D Soil Boring(s) of borings X Geotechnical s of borings <br />o Out Well 0 Out -Of -Service Well Renewal Cross -Connection Repair <br />❑ New Pump_ _.: Pump Replacement D Pump Repair s Raise Weil Casino; <br />— - - _ --- — <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary L, Air Rotary id Auger ❑ Cable Tool Push Point Lj Other _ _ <br />Proposed Well <br />Depth_ 10 ft Excavation _ in diameter _ Open Bottom ❑ Gravel PacklGravei Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth _ _ ft <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched __ L Steel ❑ Plastic L Stainless Steel I i Other <br />Grout Seal <br />Depth_ _ eZQ it 21 Neat Cement (941b beg/5-10 gal water) ❑ Sand Cement _ _ sack mix/7 gal water <br />C Bentonite (20% solids) U Other <br />Grout Placement Method ❑ Pumped 9 Free Fall d Other ,., ❑ Relardant /Accelerator (name) <br />P E TAL <br />Installed By 73 Driller Pump Contractor D Other <br />0 Concrete Pedestal [Dimensions: Width ft Length _ ft Thick _ <br />In <br />C Christy Box L Stove Pipe <br />0 Submersible❑ Turbine D Other HP_Pump Set ft Standing Water Level <br />— nJ <br />PUMP <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 wells, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 HOUR ADVANCE NOT t - L REQUIRED FOR INSPEC t i, it •. , PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By ���� _ Date /3 .7a <br />Grout Inspection By _ _ Date <br />Pump inspection By <br />Area �Gf�i7 Employee ID# F(Allk <br />11 SPECIAL Well PermPgY41 <br />D WAIVER ReceivedRs6k-' , -- <br />eHDo43-06101512021 y Otr�n �/I ll / e�t�1or,� wen iFav t>aulit <br />