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I WELL/66MP OERMiT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLEPFRMIT rA1I/9no%orl71207rWmgm•-__-___-__ <br />---- ,///� LMR r uln I Mlr- 10Juru <br />JOB ADDRESS �Q �� �GC _CITY/ZIP <br />-/ <br />CROSS STREET CSS G',10�1 r„�\��1Ot Cit APN 90-740 d <br />PARCEL SIZE � I LAND USE APPLICATION <br />OWNER NAME ��e "'��n« ,�% _ PHONE�y-��3 aa�� <br />OWNER ADDRESSIAl,Y1/� <br />I R.. <br />a G�. !_ CITYISTATEIZIP-�.p.y.c.A�Di4 <br />CONTRACTOR J�'/l A 7PHONE <br />C <br />CONTRACTOR ADDRESS CITYISTATE/ZIP_C%�'i..5 a <br />SUBCONTRACTOR ---...- --_-_-- PHONE.--- <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP_ <br />TO <br />LICENSE ✓: C-57 C-61 L D-09 Other i NUMBER 0191 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE i Domestic/Private I Irrigation/Agricultural Industrial Water Quality Monitoring I Soil Sampling/Characterization <br />II <br />Public Water System <br />ftom <br />Il If different from Owner. Water System Name Contact Name or Phone Nwnber <br />TYPE OF WORK - New Well Replacement Well - Well AlteratlordModification Other ��A <br />Monitoring Well(s)_ # of wells r Soil Borin9( 5)_ # of borings Geotechnical # of borings <br />Out -Of -Service Well E Out -Of -Service Well Renewal Cross -Connection Repair J/' <br />_ <br />/New Pump Pump Replacement I Pump Repair Raise Well Casing $ <br />WELL CONSTRUCTION ,�N✓ <br />0 <br />Drilling Method . Mud Rotary Air Rotary Auger Cable Tool Push Point Other HZ' <br />ENV qQ <br />Proposed Well Depth it Excavation in diameter Open Bottom Gravel Pack/Gravel Size in <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter — in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft i Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20%, solids) I Other <br />Grout Placement Method i Pumped Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions Width ft Length ft Thick <br />in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set LTO ft Standing Water Level _,a"? ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <br />Coordinates, property lines, adjoining properties. water bodies or courses, drainage pattern, roads, existing wells, %tructuret, <br />potential sources of con tit mination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Aricuiture. Industrial well. provide locatioriof any water wells or surface water within 200' radius of proposed well. <br />1!\1111 Ili'•I t: 11)1,1\( E NO WE REQI'1RED IrOR INSPECUIONS- t't.EASL• CALL 11091 9i3-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �Z— _ Date rob 7 <br />1,32_ Area Employee ID.. A r7 _ <br />Grout Inspection By _ Date n' SPECIAL Well Pei nit <br />Pump Inspection By Date/ 2� �-(� WAIVER Received <br />Soil Boring Inspection By Date Constructed Well.Depth ft <br />COMMENTS /�1e.ti.l we.�i �,��Ivt►� W�UUtYIic�I�i__ '�3�) � �3�f�..5�,►n�in<; <br />T <br />m <br />D <br />0 <br />o <br />IA <br />y <br />N <br />PE <br />Codes <br />SC Received Check#/ <br />Into B _ Cash <br />Amount <br />Remitted <br />Dat Permit/Invoice # Well ID# <br />Servic%est # <br />- <br />4390 <br />1 I <br />I <br />-a <br />22A0V <br />EHDO43-06 61107;220212 <br />Ns7oz-7(," <br />N. I or'_ <br />Well, Pump Pe"T <br />CIO O ���y' <br />T k* <br />