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I , I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL <br />(2U9) 953-7697 FOR INSPECTIONS <br />t_AVIII 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS (� !�� <br />p <br />BQ00(c S1Dk XV <br />CITY/ZIP <br />�iatno � i, r?_ 7 <br />/%�` <br />CROSS STREET ! tet, (�_% <br />APN <br />7 <br />f10190 0J <br />PARCEL SIZE 18.3 LAND USE APPLICATION # <br />OWNER NAME j/0(�y0n/ <br />S(i►'{M) D(9 <br />r1 <br />PHONE <br />OWNER ADDRESS `� <br />,V/VI✓/L��el.7 <br />/1' *015(p.— <br />Ll- <br />CITY/STATE/ZIP <br />/�/� 0 -A- <br />f-joeX ropy . (�i7"7` <br />CONTRACTOR 1/1�i &VA -LF <br />CONTRACTOR <br />-kv/441, <br />t¢S��f��OCPA-/0 <br />IT/3_2 <br />/T!�y <br />CONTRACTOR AD DRESS 105(7 <br />�/i1p{,1r-te1ii <br />`f VrY, <br />CITY/STATE/ZIP <br />',P/HONE�7�b��!Z <br />/ , f-+L�i ? If/ <br />SUBCONTRACTOR 1/ <br />//V) Y �( VLt <br />NG�/� <br />`64 * <br />� !) � /" ) i Gam) <br />SUBCONTRACTOR ADDRESS <br />`` <br />�i 4fl �C u jlIg,( PIZ <br />CITY/STATE/ZIP <br />�PHH/O�N/E <br />LICENSE i ri C-61 <br />D-09 Other <br />NUMBER -)7112 '?19/ <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE a Domestic/Private L-1 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 D Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings AGeotechnical # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Il Pump Replacement ❑ Pump Repair i Raise Well Casing <br />Drilling Method ❑ Mud Rotary J Air Rotary ;4,Auge;� C Cable Tool - Push Point ❑ <br />Proposed Well Depth /S,- TO ft Excavation 9 in diameter ❑ Open Bottom <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />Other <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad [I Steel i l Plastic <br />Grout Seal Depth � -- fO' ft X Neat Cement (94 lb bag/5-10 gal water) CI Sand <br />I I Bentonite (20% solids) ❑ Other <br />Grout Placement Method r Pumped /Free Fall KOther T. I-A41C. Retardant / Accelerator (name) <br />Gravel Pack/Gravel Size in diameter <br />_ft <br />I Stainless Steel Other <br />Cement sack mix/7 gal water <br />PEDESTAL Installed By - Driller ❑ Pump Contractor <br />❑ Concrete Pedestal ❑Dimensions: Width ft <br />in Christy Box L� Stove Pipe <br />Other <br />Length <br />ft Thick <br />PUMP Submersible[] Turbine i 1 Other HP Pump Set ft Standing Water Level �9(.i/.¢ <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,.iUkctPr?s,, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property Iines.SF%�o r� Domestic,' <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well,ENJIRONIN CO( <br />MINIMUD A ROUR ADVANCE NOTi _ s REQUIRED FOR INSPE IONS - PLEASE CALL (2 953-769- HEALTH DE <br />A4' ISA <br />DEPARTMENT USE ONLY y�C <br />Application Accepted By Date /;?a Area Ohiot�4"A Employee ID# <br />Grout Inspection By Date S1 16 Z ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Ispection Py Date Constructed Well Depth ft <br />COMMENTS i5 1 0 I) ��� <br />T <br />Ic <br />7Y <br />PE SC Received Check#/ <br />Codes Info Ely 4 Cash <br />gra <br />Amount Dat <br />Remitted i <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD043.0604/07/2012 Pagc I of Well, Pump Prnnit <br />