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Docu&i n Envelope ID: FE40C912-2OAl-4499-9517-3G3D80C2F8DO <br />4 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL (LUJ) J5.5-/bV i FOR INSPECTIONS tXYIKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />_If/ <br />117lrll, Ci% ! NU:11L CITYIZIP <br />Date Permit/ <br />Service Request # <br />2 y <br />CROSS STREET <br />qq <br />/ n i 1ae4l 9 <br />j /� / rc.1 <br />tl�ll- -0q ` 6C, '1- '-Oj 'PARCEL SIZE i/0) hr LAND USE APPLICATION # <br />OWNERNAME <br />LM/gTr.ilr'•%( <br />/A�PNI ��✓ <br />ln.} �1a7A C! Jr—tt , 'imel <br />PHONE <br />OWNER ADDRESS <br />L 41, <br />i✓ti CITY/STATEIZIP <br />CONTRACTOR <br />t.�(Fr Y_�i!1('U!►'%�tjl1 <br />// //C ff{ <br />(e &i"lu WGvdC�)t.4% fine <br />PHONE_p <br />CONTRACTOR ADDRESS P_35_ -,,K <br />(� C,7G'� [ivP Gill O'Il ( 2 �i CITY/STATE/ZIP <br />7''a -w., t/ C� / /% y 91 <br />SUBCONTRACTOR W-tL(AtiX_ "- <br />SUBCONTRACTOR ADDRESS 3f)5G .I-/ld{ojj� 't:X [ t3,,cyl r t �•�cY <br />LICENSE eL 1:-57 D C-61 U D-09 I, Other NUMBER <br />PHONEG(i <br />CITYISTATE/ZIP We-Sd <br />EXPIRATION DA <br />DOMESTIC WELL SAMPLING::: General Mineral/Coliform Bacteria (4391) Dibromochioropropane (4392) .... Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural D Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK f" New Well t'.I Replacement Well CI Well Alteration/Modification C Other <br />Monitoring Well(s) # of wells ;-W Soil Boring(s) Z s! of borings [1 Geotechnical i! of borings <br />Out -Of -Service Well 1 Out -Of -Service Well Renewal 3 Cross -Connection Repair <br />IN OW <br />WELL CONSTRUCTION <br />Drilling Method r.] Mud Rotary r.] Air Rotary Ia Auger 0 Cable Tool Push Point JC; Other 0117 <br />Proposed Well Depth_.5't'`J' ft Excavation Z in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter 4& in Thickness/Gauge/ASTM Sched ^ Steel C Plastic r Stainless Steel C Other <br />Grout Seal Depth 50 ft V.' Neat Cement (94 lb bag/5-10 gat water) L Sand Cement sack mix/7 gal water <br />CI Bentonite (20% solids) C Other 14'4--4/ <br />Grout Placement Method f_; Pumped `u Free Fall 9' Other trnr �r t �°"Kia Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller C' Pump Contractor 0 Other <br />0 Concrete Pedestal ODimensions: Width ft Length ft Thick <br />in :, Christy Box i., Stove Pipe <br />PUMP r'l Submersible[] Turbine E, Other HP Pump Set ft Standing Water Level It <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. Llclude 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 />MINIMUyI 24 HOUR ADVANICI' tiO'I'IC F.. Rll'"Q(ARED FOR INSPECTIONS -PLEASE, CALL ( dol 953-76+)7 <br />DEPARTMENT�+ZX <br />ONLY <br />Application Accepted By _ Date Q 27— <br />Grout Inspection By __.......__.._ Dale <br />Pump Inspection By _ <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area S (� Employee ID# 14-3 <br />I SPECIAL Well <br />iJ WAIVER R2CHIlitf <br />Constructed Well Depth d.._ <br />rn <br />PE Sc <br />Codes Info <br />/� <br />ReceivedCheck#1 <br />By ash <br />Z <br />Amount <br />Remitted <br />_ 2 .'' <br />Date Permit/ <br />Service Request # <br />2 y <br />V 0 <br />InvA_' NMEN 11D# <br />fl D <br />- -- Ems-- - <br />M ID0:0-114 ei Yl'Y:0_'? Vatic 1,42 we.n : rrrr, r Vernor <br />