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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 955-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Ol7 0 calm )"t rKso-,* CITYI�ZIIP �!rgPO.A 7/Q!N ({Q✓f F q:S 1 CROSS STREET ZIAW14 APN Zy4 ^ 06P ^ 420 -##o PARCEL SIZE A f9. i b LAND USE APPLICATION #_ OWNER NAME 54w/ONV I (AJ06- Q,T)r E?Rt. PHONE //�n Q OWNER ADDRESS ��7/ a+ . _ tl.� • QV A/i.4M FFa¢y 2d CITYISTATEIZIP ��+r�4� ee _ 64 • S'7y Y % !CONTRACTOR V 4; QORIa t•t,V fr n /�P�HHONE a//�� Yf►Q^77007 CONTRACTOR ADDRESS /If7 r7fL��'k �fi�Ii.i !- {�I�t�� CITYISTATE/ZIP Ce4!d j "4 qg rol.1 SUBCONTRACTOR f%_4«r+e'P - /cwt 4 41forlll-woi PHONE 9�A`L� �`G5� �'7 `y SUBCONTRACTOR ADDRESS TO It? l�6rha/ii•+r y ✓D �CIITT�YIISSTAATFJfZ�IrP kV • r'4 C , elf 1 -r6 fj ..r LICENSE AC -57 - C-61 D-09 Other NUMBER / W 107 EXPIRATION DATE DOMESTIC WELL SAMPLING: 0 General MineraUColiform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) INTENDED USE Domestic/Private Irrigation/Agricultural Industrial - Water Quality Monitoring 'k Soil Sam plinglCharacterization Public Water System If different from Owner. Water System Name Contact Name or Plane Number TYPE OF WORK New Well Replacement Well Well AlterationlModification Other Monitoring Well(s) # of wells Soil Borings) # of bonngs 19 Geotechnical �of boder Out -Of -Service Wall Out -Of -Service Well Renewal Cross -Connection Repair New Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary - Air Rotary XAuger Cable Tool Push Point Other Proposed Well Depth 1 S -Z a ft Excavation In diameter Open Bottom Gravel Pack/Gravel Size Conductor Casing in diameter I Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other Grout Seal Depth ft kNeat Cement (94 lb bag15-10 gal water) Sand Cement sack m Bentonite (20% solids) Other Grout Placement Method Pumped X Free Fall Other r�'t►E IF O Retardant I Accelerator (name) Installed By : Driller Pump Contractor Concrete Pedestal Dimensions: Width Christy Box Stove Pipe Other ft Length ft Thick in diameter IAWN NT ED Pump Submersible Turbine Other HP Pump Set It Standing Water I - Wei � 0 1 Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followi4 fttt 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 front two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. N11NLNIt AI 24 1101. K L Nen I( I. REQUIREF) I Ok INSPI.(- I tins - PLb:nst. C.U.I. (201)) 9.53-76107 DEPARTMENT USE ONLY Application Accepted By� L� Date a ` %t� Area Employee ID# ' 1� Grout Inspection By _ pill'.),, N 1. 1.i -'Z Date (, Y 17 j L c ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Sal Boring Inspection By COMMENTS Date Constructed Well Depth ft PE Codes Sc Re ived Check#1 Info B Cas Amount ate PermiU Invoice # Well ID# Remitted Service Re uest # Iso 09 t I cHtxu i -M, Id; W201 P"v 1 ""2 Wel P—P P""ii UNTY T