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1 WELL/PUMP PERMIT <br />SAN JOAC?UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT rel 1 17n01 oc'2 <br />''],7� \,� `/ r JJJ�IWOI rUK INbVLGIIONS EXPI ES 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 4 l 1`j <br />�J�J� \V <br />CITY/ZIP G �1 <br />v^� 1f _ <br />CROSS STREET \ � <br />APN I U�p �ARCEL SIZ4LI LAND USE APPLICATION I <br /># wrlb <br />OWNER NAMEQn <br />PHONE <br />OWNER ADDRESS _ \yW � ` <br />S <br />CITY/STATEIZIP \k N A to <br />CONTRACTOR <br />PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />0 <br />710 <br />PHONE I7 MJ <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE XK57 ❑ C-61 ❑ D-09 ❑ Other NUMBER O�J EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i 'General Mineral/Coliform Bacteria (4391) : Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE J Domestic/Private ❑ 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 />El Monitoring Wells) # of wells *` <br />oil Boring(s) # of borings PkGeotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casin <br />WELL CONSTRUCTION <br />otary` <br />Drilling Method C Mud R, E)Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point Ids/ Other <br />Proposed Well �6 <br />Depth t cavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />U Conductor Casing <br />in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/ auge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ OthP <br />Grout Seal Depth_ft Neat Cement (94 Ib bag/5-10 gal water) Sand <br />❑ Cement c dai yaaier <br />Li Bentonite (20% solids) .2 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall )R.-Olher Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal [I Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe EN QU/ <br />PUMP U Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water rA <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items. S <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 />:41IOl'IL:11)1ANCI:1'(>J'1('ER1,011IKe_I)IORIN'S1111a'l'if1\ti <br />DEPARTMENT US''EP N L Y <br />Application Accepted Byate +�— f� Cji <br />D Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well P@IT111t <br />Pump Inspection B Date ❑ WAIVER ReceiveI <br />Soil Boring Inspection By Z"Z <br />Date I <br />_ Constructed Well Depth III ft <br />COMMENTS <br />i <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B Ca h Remitted Date Service Request # Invoice # Well ID# <br />y " 77 / c G"' •22 00 <br />nrma�_na namnmo '. <br />Page"" <br />Well /Pump Permit <br />T <br />