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t WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT i — CAI 1 /9nm QA3_7RQ7 t=rio IRicncf nnPto ovoio=c A v_.— <br />JOB ADDRESS CITY/ZJP <br />CROSS STREET APN ' 0 PARCEL SIZE _J_LAND USE APPLICATION # v� <br />r <br />OWNER NAME PHONE 4)q- `"c E (.L/ L I <br />OWNER ADDRESSc} CITYISTATEIDP ) <br />CONTRACTOR ( <br />PHONE L / <br />CONTRACTOR ADDRESS Cie CnY/STATE211' <br />SUBCONTRACTOR 1 PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 D C-61 ❑ D-09 D Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE ; Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification D Other <br />Monitoring Well(s) # of wells D Soil Boring(s)a of boringsc —I In p f <br />❑Geotechnical _ V f V 7' <br />Out -Of -Service Well n Out -Of -Service Well Renewal u Cross -Connection Repair �D <br />New Pum Pump Replacement D Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION I122 <br />Drilling Method Mud Rotary D Air Rotary D Auger Cable Tool Push Point D Other SAN 10 <br />Proposed Well Depth ft Excavation in diameter D Open Bottom ' Gravel Pack/Gravel �N��VIIRpn�n t <br />C Conductor Casing in diameter / Conductor Casing Depth ft E ~RTMENT <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel D Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft D Neat Cement (94 Ib bag/5 10 gal wafer) D Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) D Other <br />Grout Placement Method Pumped D Free Fall D Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 7, Driller D Pump Contractor Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in Ei Christy Box D Stove Pipe <br />44 <br />PUMP Submersible D Turbine D Other HP Pump Set ft Standing Water Level 4 01ft <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 />;; D OR i ` 6 ECTiONS - PLEAS' _-1L (20) 9;;3-76Q . <br />DEPARTMENT USE ONLY <br />Application Accepted By '--' Date d e J <br />Area 1 % Employee[D# Prz i 61 k , <br />Grout Inspection By A A Date)) ❑ SPECIAL Well Permit <br />Pump Inspection By Date t 1) ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS vie,, <br />I l L <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B Cash Remitted Date Service Request # Invoice # Well ID# <br />A <br />�nwvavo uviu ntutt (y IF—Page 1 oft <br />Well / PurtT Permit <br />I'l- 1 � 3 3 1 / <br />_so <br />M <br />a <br />0 <br />0 <br />M <br />M <br />y <br />N <br />