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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERM <br />L;ALL ZUy 9bJ-[bVI FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />lT <br />�I <br />I� <br />JOB ADDRESS 730 1 Sr xT <br />-1 6 9 y r�.oA4. 4 <br />c <br />CITY/ZIP J7Qan�N {przi <br />CROSS STREET WAr%lt/�i %%. <br />/rl� <br />APN I Q - olL9 - 1,90 <br />p%t;,9 <br />PARCEL SIZE 1•YS LAND USE APPLICATION # <br />OWNER NAME Sc 6' P!!E'06a yIEf <br />Lli G <br />PHONE <br />OWNER ADDRESS T i0 I9AtT4 .0E <br />'f(R,A44P J" Z 2j <br />CITY/STATE/ZIP fv�, yyA►�I C4 <br />CONTRACTOR w4 Lt, 4a -k-4, <br />AAtfw4,f4IFF <br />PHONE(9/V77z-/rrY�y <br />CONTRACTOR ADDRESS70f0 I~-I,&)Al, BWp <br />``/ <br />CITY/STATE/ZIP ;df4e GA 'DJ fl <br />, <br />SUBCONTRACTOR V 4 it-, DA)l/L <br />qy <br />PHONE fiw-� q6, ?-7'7A9 <br />SUBCONTRACTOR ADDRESS NY; � <br />CITY/STATE/�ZIP a -4kr � C.4 f �67L <br />LICENSE 2(C-57 I C-61 Ll D-09 <br />[I"7497Other <br />NUMBER "`AT07 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Ii Domestic/Private i-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 I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />F1 Monitoring Well(s) # of wells Soil Borings) S # of borings ❑ Geotechnical # of borings <br />I I Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I! New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary I I Air Rotary fiCAuger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth /S^ Zr ft Excavation in diameter ❑ Open Bottom 17 Gravel Pack/Gravel Size in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel I I Other <br />Grout Seal Depth iS -,;t 5 ft (Neat Cement (941b baV5-10 gal water) ii Sand Cement sack mix/7 gal water <br />'I Bentonite (20% solids) I I Other <br />Grout Placement Method I Pumped )� Free Fall )¢ Other r'QNbi /C N,.✓ ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 1"1 Driller I: i Pump Contractor ❑ Other <br />Concrete Pedestal IiDimensions: Width ft Length ft Thick <br />in I Christy Box -I Stove Pipe <br />PUMP i Submersible❑ Turbine I i Other HP Pump Set ft Standingv ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the fol iw"T <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existiWLrYHI3EW14 KMT, <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 />NIINI\Il 11 24 11011( AD\ kV( V NO 1( 1% RL01IRLD FOR INSPE(TIONS - l'LFASL ('AIA. (2119) 953-7097 <br />T DEPARTMENT USE ONLY <br />/ <br />Application Accepted By �/�— � /-- Date7S ?.2 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By /V fi (5 &1m Date ?'U-% -2,02--" <br />COMMENTS <br />Area -I S� Employee ID# (ie3 t1 k <br />❑ SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />S rvice Request # <br />W37.7 <br />- <br />iso <br />S <br />f)O(V •IS -2 <br />0 <br />EHD043-06 04/07/20 % f / -� 3 1 _5 t_ 6 Page I of'2 Nell / Pump Pernm <br />