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I WELL/PUMP PERMIT F® SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HIAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED ^` f w Joe ADDRESS Sol Al./l Ac q cm - Ave -Crrr/21P iP/_ Ao.N9 r l 6 6 1.l I:ROSSSTREET. _W•_IVIAiAJ AP(,f L!�-OyD-/rd-POPPARCELSIZE _ T M NT IPEOE$rAL Installed By - Driller .- Pump Contractor Other Concrete Pedestal!-. Dimensions: Width ft Length ft Thick LAND Use APPLICATION# /�F�• IOWNERNAME 1IPQ� V/V//� O J,wooJ p(mel PHONE OWNER ADDRESS �� / �' III& i A 6 CITY/STATE/ZIP _ /C. //�BAf , {� /� �11 q f.j `A CONTRACTOR A«� --KVWL f 4J;@e 44fe PHONE (,?/#) 37I 'l7 .7 t/ CONTRACTOR ADDRESS1 �4IQyJ1 R.l � v '01.VD CITWSTATE/ZIP V�It I�I0*4l{1,0 C'4 M fl /Yo�y SUBCONTRACTOR if 14'., 1%tlbb/N 4 �I�/G, I/ ■ PHONE kll T/ 7 '-77O0p SUBCONTRAC��T� It✓�I'il!l/NG>l1 D,t„ CITY/STATE/ZIP/i/A�� C/f ps6� - 'RADDRESS �T /O LICENSE 1iC-57 11 C-61 '-' D-Og Other _. NUMBER 7Z� TO + EXPIRATIONDATE 7/Pd/ZI I DOMESTIC WELL SAMPLING: General Mine raI/Coliform Bacteria (4391) Dihrmmnrhlornnrnnana 144991 Arecr.i rn'�ow INTENDED USE 1- DomesticlPrtvate I Irrigation/Agricultural .7, Industrial Water Quality Monitoring Soil Sarn fin /Characterizsiion Public Water System_ It different from Owner Water System Name Contac! Name or Phone Number Tv rte m m O 0 I m - - - vv U, a'.. , rvc„ vven Hireranortimooltication I i Other Monitoring Well(s)# of wells r Soil Boring(s) ;* of borings Geotechnical _/ of borings F, Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair __ Pump C Pump Replacement `11 Pump Repair f] Raise Well Casing �� ItAlELL CONSTRUCTION 0.New Drilling Method Mud Rotary I I Air Rotary F® Auger C Cable Tool Push Point LIOther Proposed Well Depth 20 6�F® It Excavation in diameter Open Bottom - Gravel PacklGravel Sizeryt� iam er F, Conductor Casing in diameter / Conductor Casing Depth ft SO Well Casing Diameter _ in Thickness/GougeIASTM Schad 1. Steel 11 Plastic -I Stainless Steel Other 4� 111 " Z Grout Seal Depth_ 'P 90 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement --sack mix N00, Bentonite (20% solids) '' Other p Grout Placement Method _ Pumped J(• Free Fall Other 111"t r r ": Retardant /Accelerator (Hama) T M NT IPEOE$rAL Installed By - Driller .- Pump Contractor Other Concrete Pedestal!-. Dimensions: Width ft Length ft Thick ___ In Christy Box StPipe Stove _ I LE—umP Submersible Turbine . Other HP Pump Set It Standing Water Level - f Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS 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 from two property lines. For Domestic, Agriculture, Industria) well, provide location of any water wells or surface water within 200' radius of proposed well DEPARTMENT USE ONLY Application Accepted By—Tz L Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS Date S a7 22 - Date Date Date Area Akwi Employee ID#A(7 SPECIAL Well Permit WAIVER Received Constructed Well Depth ft PE Codes Sc Received Chec Info ash Amount Remitted Date PermiU —� Service Per-nit) Re uest III Invoice # Well ID# �a SO 60 " Z ��