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1 WEILIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 NON-REFUNDABL EPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEISSUED JOB ADDRESS ( CITYIZIP m CROSS STREE219-Zq0 240 T APN C PARCEL SIZE F�ANDU'JE APP{{LIGATN)N#n/� vyf M U m OWNER NAME PHONE OWNER ADDRESSY CRY/STATtEI1'JP C ��i CONTRACTOR J �� V' PHONE ��- I 1 Q`�/��//r/ CONTRACTORADDREas C"STATEIZIP nj9OW / Ga 95'x`1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CUWSTATEMP LICENSE C-57 0 C•$1 ❑ D-09 ❑ Othefrr NUMBER P— EXPIRATION DA 1-!FD - / DOMESTIC WELL SAMPLING:E General Mineral/Coliform Bacteria(4391)L Dibromochbropropane(4392)C Arsenic(4393) INrENDED USEOomesticIPrivate ElIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization Public Water System H dteerw t imm Owner Water System Name Cattell Name or Phone Number TYPE OF WORK VNew Well ❑ Replacement Well ❑ Well Alleratio~ification 0 Other ❑ Monitoring Well(s) #of wells ❑ Soil Borings) #or borinpr ❑ Geotechnical 0 of borings ❑ Out-0f-service Well ❑ Out-Of-Service Well Renewal O Cross- onnection Repair ❑ New Pump ❑ Pu ent ❑ Pump Repair O Raise Well Casrg WELL CONSTRUCTION Drilling MethodMud RAir Rotary ❑ 0 Cable Tool C] Push Point El Other Proposed WellIpth ft Excavation _in diameter ❑ Open Bottom Gravel Padt/Gravel Siz.-Jjp in diameter 0 Conduct Casing in diameter / Condu �sing Depth ft Well Casing Diameter in Thicmess/Gauge/ASTM Schad 51l ❑ Steel Plastic O Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mixf7 gal water Bentonite(20%solids) ❑ Other PAYMENT Grout Placement Mathcwd Pumped ❑ Free Fall ❑ Other O Retardant/Accokoator(name) RECEIVED PEDESTAL Installed By O Driller ❑ Pump Contractor 0 Other 't ❑ Concrete Pedestal DDInwahxns:Width it Length it Thick in ❑ Christy Bolt ❑ Stove Pipe snNnauw cuunr't v"'F. PUMP ❑ Sub(nersible❑ Turbine O Other HP Pump Set ft Standing Wa&rLt�ti�Pna ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property fuses, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contzmination,sewers or private disposal systems. Include distance from two property lines.For Domestic, Agriculture,Industrial welt,provide location of any water wells or surface water within 200'radius of proposed well. 11,. 4x1,,, A1)�.0,!, f '�•.'-i lLIJ(!Rd.)ir•r)Z!'• _ ..'\', .t..\?t •.i.:.,a!`�. DEPARTMENT USE ONLY Application Accepted By _ �'�/` `—� Date C a Area Employee ID# Grout inspection By Data ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Conshimted wen Depth ft COMMENTS�iL 10}i.I^ 1O" S( its k +L� d�7 r 1 ` S 50aI ; �.i�n-i t'"[A1:irl lC-� 1U� �'r F•�� Sf• f�GlGF'� r6°l�Gi� PE SC Received Checid/ Amount PerTnw Invoice>X Well IDN Codes Into By PRO" Rernifted Service Ertoa;m io2um¢Ic7 ` (f' r.�i orz t.i'`S�� i/ 2-- W01 ftnns