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LLI <br />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 p�CALL ZD9 963-7697 FOR INSPECTIONS CArlf[eQ T GAR rmu1Y1 VH 1 r- loouGu <br />JOB ADDRESS S% �Q E- 1 / 5 A' CI Y1ZIP <br />CROSS STREET C),17 13 11 APN 190(' �`� PARCEL SIZE �; ) 7 LAND USE APPLICATION # Q <br />OWNER NAME .[I'�(G/� V, -e CO— /PHONE 109 ' � b 'Z — i+ Z so <br />OWNER ADDRESS �� 1s5 7 oD //P of o� CITY/STATE/ZIP / //R✓I � e G4 ' 3- -3 3-7 J�� <br />CONTRACTOR I nm 5 \y✓YIIQ 5-ef1�I c- /"P�HOjNNE�2C)q !7,99 —3qg `e <br />CBNTRACTOR ADDRESS Oy 5 `7 c 0c, 0 -'e , ' � CITY/STATEIZIP 'l. ei gh Q ! (2q • I <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITYISTATFJZIP, <br />LICENSE ❑ C-57 61 ❑ D-09 ❑ Other NUMBER 2 <br />PHONE <br />EXPIRAnoN DATE -->V — <br />DOMESTIC WELLS LING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boling(s) # of borings ❑ Geotechnical # of borings <br />❑ 9pt'-OfService Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />VNew PUMD ❑ PUmD ReDlacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <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 <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft RECEIV <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack Illiwgo u51te1 <br />❑ Bentonite (20% solids) ❑ Other LL <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) ""JP""'''"' (- 0 I1N <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other tDulh �-CS �.:17!•f I'T'alCi1-V <br />❑ Concrete Pedestal ODimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑ Other HP � _ Pump Set OU ft Standing Water Level --ft <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 />IHNIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2039) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L� <br />Grout Inspection By <br />Pump Inspection By <br />Date S $ .� <br />Date <br />Area S C Employee ID# A <br />ElSPECIAL WO11 Permit <br />Date 26 TLA&= A -2-L— ❑ WAIVER Received <br />Soil Boring Inspection By Date <br />COMMENTS th W IJOH �(' !I^' L� FO�1`ID$ �7 - 14 <br />w <br />-Z <br />Constructed Well Depth <br />1pida" <br />ft <br />PE <br />Codes <br />SC Received Check#/ <br />Into EW Qpsh <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />'I <br />1 <br />rage 1 oft Well i Pump Permit <br />