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v <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />AInKI_Pccr rnrnA4r c PCOIUIT r01 I 0nQ1 953.71197 FnR INSPFr-TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ClOSt� L.DaE J�Ec. 9,1• CITY/ZIP ES�—_ -4LON � <br />l 94� <br />CROSSSTREET�t1QtAj '/r APN 40 -A(0-��[pARCELSIZE USE <br />�/IAPPLICATION <br />!It <br />OWNER NAME � �1 V 1/ 1!11+.1 ✓ L I AC T_ �� (� /PHONE /'\� -" of - 14L <br />OWNER ADDRESS 1� 2a L_ o 1yA e -C 1c_C E Y-9,. CITYISTATEIZIP (�SC.Ai oW o G4l, 953 <br />CONTRACTORpl-, KAo PHONE A,. <br />) <br />CONTRACTOR ADDRESS O 0\1- Q CT �{ I CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 C-61 ❑ D-09 ❑ Other NUMBER A7rLjqAj EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General MinerallColiform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED U3E ❑ DornesticfPrivate XIrriSation/Agricultural ❑ Irdustriai D Water Quality Monitoring ❑ Soil Sampling/Characterization <br />H Public Water System <br />If different from Owner: Water System Name Cor:tact Name or Phone Number <br />TYPE OF WORK ,New Well ❑ Replacernerd Well ❑ Well Alteration/Modification D Other _ <br />Fl Monitoring Weill(s) # of wells O Soil Boring(s) tl of borings ❑ Geotechnical P of borirgpw <br />❑ Out Of -Service Well ❑ Out -Of -Service Well Renewal CI Cross -Connection Repair <br />pr.New Pimp ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well CasingC I <br />WELL CONSTRUCTION <br />Drilling Method [I Mud Rotary ❑ Air Rotary ❑ Auger El Cable Tool Cl Push Pcint ❑ Other MAR O <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom O Gravel f acklGravel SizeSAN . in diam t <br />❑ Conductor Casing i..i diameter i Conductor Casing Depth ft N Ntr✓ q QVIN <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel 11 RCN C 1 <br />Grout Seal Depth ft O Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mia <br />E Bentonite (20% solids) tl Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant i Accelerator (name) <br />PEDESTAL Installed By ❑ Driller t Vump Contractor, .,E Other <br />X Concrete Pedestal yDimensions: Width �� It Length it I hick l O <br />]in C Christy Box ❑ Stove Pipe <br />uMP ❑ Submersible l�.Turbine H Other HP 100 Pump Set kd ft Standing Water Level 0_ tt <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 fron► 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 />NIININ1L1P1 24 HOUR ADVANCE NOTICE, REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTNI ENT US E ONLY <br />7 <br />Application Accepted <br />By fF— Date ��'��.� Area l / / Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By e_ Date Z "A o ❑ WAIVER Received <br />Soil Boring Inspection By L Date Constructed Well Depth ft <br />w <br />COMMENTS ('_II FL f �' ! VJ FQ 0 `')f Z; 6f%' COQ4W bil ".�L_ - )4� <br />D <br />0 <br />A <br />M <br />C? <br />PE <br />Codes <br />SC Received Check#I <br />Info B Cash <br />Amount Date Permit/ Invoice# WellID# <br />Remitted Service Request <br />�138Q <br />o <br />I <br />EHD043-06 10125/:021 Page 1 oft \Veil / Pump Permit <br />