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. 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />14U1V-rCEhUNUA5LE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOBADDRESS 930 N Fine Rd CiTY21PI,inr1Pn,CA 95236 <br />CROSS STREET 'Et -11.1 -rd St APN 0 43 0 4 0 2 8 PARCEL SIZE 1. 6 7 LAND USE APPLICATION # <br />OWNER NAME M <br />PHONE <br />OWNER ADDRESS 9 3 0 N F i n P R (I CITY/STATE/ZIP L i n a Pn .,C'_A ()5 2 3 6 <br />CONTRACTOR ADDRESS P . O . Box 64 CITY/STATE/zIP Linden . CA 95236 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE21P <br />PHONE <br />LICENSE M C-57 c C-61 n D-09 P Other NUMBER i 7 7 9 2 i EXPIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private n Irrigation/Agricultural f! Industrial ri Water Quality Monitoring :1 Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />0 New Well n Replacement Well 11 Well Alteration/Modification n Other <br />Amount <br />Remitted <br />Permit! <br />Date Service Request# Invoice# WeII1D# <br />n Monitoring Well(s) # of wells I"i Soil BOring(s) m of borings ; t Geotechnical <br />9 ° P14Y <br />77 <br />n Out -Of -Service Well n Out -Of -Service Weil Renewal n Cross -Connection Repair <br />/C <br />.1 New Pump kump Replacement n Pump Repair II Raise Well Casing <br />WELL CONSTRUCTION IA� <br />Drilling Method <br />Proposed Well <br />i I Mud Rotary Ii Air Rotary - Auger 11 Cable Tool : ; Push Point n Other SA A,�f 7 <br />Depth ft Excavation in <br />diameter F Open Bottom Fi Gravel Pack/Gravel <br />S'eEnrJu7 diame 8r <br />�7 <br />I Conductor Casing in diameter 1 Conductor Casing Depth ft <br />4C ON CO <br />�F6 COO <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched P Steel n Plastic ;1 Stainless Steel <br />11 Other <br />Grout Seal <br />Depth ft r Neat Cement (94 lb bagl5-10 gal water) C Sand Cement <br />sack mix17 ga T <br />f I Bentonite (20% solids) F. Other <br />Grout Placement Method t; Pumped i; Free Fall 1 Other i Retardant /Accelerator (name) <br />PEDESTAL Installed By n Driller f1 Pump Contractor i Other <br />F1 Concrete Pedestal I]Dimensions: Width ft Length ft Thick <br />in Il Christy Box r I Stove Pipe <br />PUMP Submersiblen Turbine P Other HP i Pump Set � ft Standing Water Level f171 <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 well, proAde location of any water wells or surface water within 200' radius of proposed well. <br />// DEPARTMENT USE ONLY <br />Application Accepted By v� Date s a y as Area Employee ID# �s <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />r� <br />Pump Inspection By Date-�z Z ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS -DDLVMCA-I CparCl lnaf CS 6-r we 11. <br />T <br />PE Sc Received <br />Codes Info By_ <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Permit! <br />Date Service Request# Invoice# WeII1D# <br />9381 oG0 <br />sc�— <br />77 <br />Z W ,.3C-, <br />EHM43-06 04.07,102?� Page t of 2 well; Pump Pemtit <br />�- --l#H'f07/Fz7 <br />