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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT' �' CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS '''' 2_�3e9 2Q,J �J• /d!/' A ND• I�'1 CITY/ZIP <br />J /7/�O� 9✓/l0� <br />CROSS STREET W 11 (%//�dh /1 APN u�y� K 17 1 PARCEL SIZE . �1� LAND USE APPLICATION # <br />OWNER NAME -CV Clgr- L PHONE 20 G -gr& &2 7 <br />57 <br />OWNER ADDRESS _'Zi I"r' C' <br />CONTRACTOR Q,ri _.J L)ry Saiy� <br />CONTRACTOR ADDRESS v�� 0", <br />SUBCONTRACTOR <br />CITY/STATEIZIP <br />PHONE ,1.0 q— /9r 3 Vg -lo <br />CITYISTATE/ZIP _ #�'ci Ze <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STA <br />�TE/ZIP <br />LICENSE 11C-57 -61 ❑ D-09 ❑ Other NUMBER /O5'g J 7:5- EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />TYPE OF WORK <br />❑ Public Water System <br />f different from Owne l <br />New Well Replacement Well <br />❑ Monitoring Well(s) # of wells <br />❑ 9*0f-Service Well <br />R'New Pump ❑ Pump Replacement <br />Water System Name Contact Name or Phone Number <br />❑ Well Alteration/Modification <br />❑ Soil Boring(s) <br />❑ Out -Of -Service Well Renewa <br />❑ Pumo Repair <br />❑ Other <br />#of borings ❑ Geotechnical <br />I ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size__�iD.diamQtai <br />❑ Conduct Casing in diameter / Conductor Casing Depth ft RECEIVE Well Casing Diameter V in Thickness/Gauge/ASTM Sched ❑ Steel 2_+ -Mastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sacklllliayge 'rpt J <br />❑ Bentonite (20% solids) ❑ Other ii�•�'H <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) a;AN JOAQUIN cou <br />PEDESTAL Installed By ❑ Driller ump Contrac f ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />in ❑ Cmsty Box [IStove Pipe <br />PUMP OASubmersible❑ Turbine ❑ Other HIP _�_ Pump Set ft StandingWater Level - <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, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINIMUM 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />j DEPARTMENT USE ONLY <br />Application Accepted By L `' Date <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By _ <br />COMMENTS iJP W We <br />IyetIt IIJPaJ <br />Area S % �% Employee,D# A V <br />❑ SPECIAL Well Permit <br />Date -Ek AL1 SJ✓` l 'i` ❑ WAIVER Received <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received Check#/ <br />Codes Info <br />Amount Dato ermit/ <br />Remitted Invoice # Well ID# <br />$e ice Request # <br />t11LU4f-Ub IUMUUll • t T aJ 1, W l V / _!S PagtetV / )�, 2-, <br />Wc11 / Pump P—it <br />