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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTUEw 1888 EAST HAzELToN AVENUE-STOCKTON CA 95205 - (209) 488-3420 NON-REFUNDABLE PERMIT CALL 209 9 7687 FOR INSPECTIONS ERPIKES 7 YEAR FROM DATE ISSUED JOB ADDREss j (w a q Z CrrdLP L ,., d r» . Ca gS2 3z, CROSS STREET Du,,1 c6 Y1 APN CA 1 -1St% -11V) PARCEL SUM7.3-1121-AND USE APPLICATION # OWNER NAME VAu.rMwAdl. 1 `�tl PHONlcZqbq) 81 S- X1200 - OWNERADDREss P.V • Rex ltz CITYISTATEiZIP LrNolyn� Cr, air274 CONTRACTOR MwstillS 1krAlPc-'L11e. PHONES2Z-142-sh CONTRACTOR AODRE33 j�9 A 16ers J CITYISTATEor Atackc-4, 61le g s 3S7 SUBCONTRACTOR SUBCONTRACTOR ADDREsa LICENSE JW C-57 0 C-61 ❑ D-09 PHONE CrTY/STATE/7JP Numem i%i,$&2-7— EXPIRATION DATE LT - Z G -_Z DOMESTIC WELL SAMPLING: G General MinerallCofforrn Bacteria (4391) L Dibromochloropropane (4392) C Arsenic (4393) INTENDED USE ❑ DomestiofPrivate InigatiorgAgricultural ❑ Industrial ❑ Water Duality Monitoring ❑ Sal Sampling/Characterization ❑ Public Water System V diRsrent from Owner. water System Cabled Nerve or Ptone Number TYPE OF WORK r4l" Yuen )t Keprawrni" rreu 0 Monitoring Wens) # of wells ❑ Out-of�oe wen U TWUN rmusauarrmwunaM.ni u .+.. 0 Soil Boring(s) * 0/ bOnrr� ❑ Geotechnical t of borings ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair n Prirnn Repair ❑ Raise Well CasirV Drilling Method Mud Rotar� ❑ Air Rotary ❑ Auger 0Cable Tool ❑ Push Point ❑ Other Proposed Wel Depth IJ, ft Excavation 'LO in diameter ❑ Open Bottom -0 Gravel Pack/Gravel Size =0 6 in diamete 0 Conductor Carting in diiarnater / Conductor Casing Depth ft Well Casing Diameter 12__ in Thidmess/Gauge/ASTM Sched '100 ❑ Steel gPlastic 0 Stainless Steel ❑ Other Grout Seal Depth It ❑ Neat Cement (94 Ib bey5-10 gel water) ❑ Sand Cement sack mbrl7 gal Ovate gBentonite (20% solids) ❑Other Grout Placement Method )Y, Pumped ❑ Free Fall ❑ Other 0 Retardant /Accelerator (name) PEDESTAL Installed By 0 Driller Pump Contractor 0 Other ❑ Conersb PedesW ❑Dir a Bions: Width ft Length It Thick in 0 Christy Box ❑ Stow Pipe PUMP 0 Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. tili�i�N i ii Nirl N �t '• }l 112�..: f H. iti' ; `t f it 11 r,AaF t ILL DEPARTMENT USE ONLY Application Accepted By C/' -� Date 3 as Grout Inspection By Date Pump inspection By Date Soil Boring Inspection By Date COMMENTS ExiSfi-'tG t.Jd'6- Arm 4�� _ Employee 10*F&_ ❑ SPECtAL Well ❑ WAIVER Rom Constructed Well Depth ft er+Dou.os lkvtsrmz! ^/tq; 1 rf2 will r rum ram: