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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS aQ l �C_ • 7-5 It <br />f �lts.N �A CITY/ZPP j�� r'a(-vim "15 -7o� 7 <br />CROSS STREET AJC O� nS 3 It f A APDN Q, -r, S D10 PARCEL SIZE �c S''` LAND USE APPLLIICATION`# <br />OWNER NAME CIL)'54r 4,4&� LLC. I t���u �gv�[�d�t PHONE <br />OWNER ADDRESS % 9� <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE Y C;-57 <br />CITY/STATE/ZIP 1 U b 0. ^�� �q <br />1 3 <br />PHONE a�q �+ (6 —7 13� <br />CITY/STATE/ZIP��J C ��( to �-� Cb • -t S 3 Va <br />PHONE <br />CITY/STATE/ZIP <br />C-61 I D-09 Other NUMBER '7 3 ► a EXPIRATION DATE S - -41' _"_Q 4Q <br />DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ,ligation/Agricultural - Industrial - Water Quality Monitoring -_ Soil Sampling/Characters i <br />Public Water System.�T,pp'll <br />If different from Owner Water System Name Contact Name or Phone Number ` L. <br />TYPE OF WORK C New Well v Replacement Well Well Alteration/Modification �1 Other <br />SC Received Check#/ <br />Info By ash <br />C Monitoring Well(s) # of wells i_' Soil Boring # of borings s) Geotechnical <br />n269" <br />211 <br />Cross-Connec <br />11 a Well Renewal <br />S <br />Raise Well Cason Repair <br />C New PumpPumpWPum Replacement C Pump Repair ing <br />E paQU/N C <br />WELL CONSTRUCTION <br />L:ALTH pEP,ART 41 <br />Drilling Method yMud// Rotary Air Rotary _ Augar 7 Cable Tool C Push Point Other <br />Proposed Well Depth boo ft Excavation ab in diameter 7 Open Bottom Gravel Pack/Gravel Size fi ] in diameter <br />Conductor Casing in diameter / Conductor Casing Depth 5 O ft <br />Well Casing Diameter LlIo— in Thickness/Gauge/ASTM Sched '(,A V-1teel Plastic Stainless Steel <br />Other <br />Grout Seal Depth SO ft Neat Cement (94 Ib bag/5-10 gal water) ✓Sand Cement I O 3 <br />sack mix/7 gal water <br />Bentonite 0% solids) Other <br />Grout Placement Method Y Pumped Free Fall Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller "' Pump Contractor Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick <br />�in 0 Christy Box Stove Pipe <br />PUMP Submersible 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 />\11 \I \11 \1 Ia 1101 R At)\ ANCE NOI I( E REQI IRED Ft)R INSPLCUIONS - PH iSE CALL (209) 953-7697 <br />DEPARTMENT USE//ONLY <br />Application Accepted By Date /Z��f%Z / _ Area S- GC), Employee ID# <br />Grout Inspection By — f Date f `7 SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received z� <br />Soil Boring Inspection By <br />COMMENTS SC.0d N N <br />Constructed Well <br />n <br />T <br />-I <br />m <br />D <br />v <br />v <br />M <br />m <br />N <br />fA <br />PE <br />Codes <br />SC Received Check#/ <br />Info By ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />� - f, Well -Pump Permit <br />rlloo�s.x, 107. ,�,1 C �, /' /3SI.J _0 <br />