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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTH <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />APN t!%� <br />OWNER ADDRESSy 7 L� J0,ki (,�1_, spy a <br />CONTRACTOR <br />CONTRACTOR ADDRESS ,) �:)O <br />TON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />SIZE 'J LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZJP (! y / I L ' , c, CA 953 <br />PHON4!n) aS�3 <br />Cmr/s ATEiZIP ( V✓1 O -K_ <br />SUBCONTRACTOR w I t'�. PHONE <br />SUBCONTRACTOR ADDRESS CITYIS�ATE/ZIP <br />LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ExPIRATION DATE J �� <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE Xomestic/Phvate ❑ 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 Boring(s) a of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ jCross <br />`FkNew Pump ❑ Pump Replacement ❑ Pump Repair n RnisP <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger fl Cable Tool ❑ Push Point <br />Proposed Well Depth ft Excavation in diameter ❑ Open <br />❑ Conductor Casing in diameter / Conductor Casing Depth _ <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retarc <br />❑ Geotechnical of C�/ N 7. <br />Connection Repair 0 <br />Well Casino 11IA, <br />10 Other JD v <br />ottom ❑ Gravel Pack/Gravel Sif E td <br />ft <br />tiRT <br />❑ !Plastic ❑ Stainless Steel ❑Other f ' /- <br />❑,and Cement sack mix/7 gal water <br />Accelerator <br />PEDESTAL Installed By ❑Driller �i Pump Contractor � Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑Christy Box ❑ Stove Pipe <br />PUMP ,)3CSubmersible❑ Turbine ❑ Other HP Pump Set 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date F /S <br />Grout Inspection By Date <br />Pump Inspection By Date IA�(n2ib2Z <br />Soil Boring Inspection By Date <br />COMMENTS _fl.,vJ W' IrJ Fa7(')V1y L1 rf 3 <br />Ic>.,::'+�1:'ii (- "m ; '--�1nr, s 6, <br />Area s �' 6� Employee ID# <br />11SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc Received Check#/ <br />Info Cash <br />Amount <br />Date <br />Remitted <br />PermiU <br />Service Request # Invoice # Well ID# <br />I <br />I <br />EHDO41-06 04/07/222 <br />Page I oft <br />)�SIoggS/ <br />W 0 A y Well / Pump Perms <br />C <br />