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4 <br /> 1 WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,A'7N f �e �`d e� S `� CITY/Zip ��i �J ��Z m <br /> Q D <br /> CROSS STREET CCS I►2�ryry6 Q 1 APN O-7a 1 C)�� PARCEL SIZE /� LAND USE APPLICATION# <br /> OWNER NAME l0it,"f ��`rE� PHONE Z—O 9-03 9—6 3s--7 m <br /> OWNER ADDRESS -5 6i 04'e CITY/STATE/ZIP <br /> CONTRACTOR nAS 1, PHONE Lti7 r <br /> CbNTRACTOR ADDRESS CIW-$TATE/ZIP InIf o b .. <br /> SUBCONTRACTOR __ PHONE <br /> SUBCONTRACTOR ADDRESS C17Y/STAITE21P \\ <br /> LICENSE ❑ C-57 C-61 ❑ D-09 11 Other NUMBER I U5 2`}i-TT EiXPIRAT1oN DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Q Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner Water System Name Conlact Name or Phone Number <br /> TYPE OF WORK ❑ New Well i. Replacement Well ❑Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s)_ #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of boring <br /> ❑ Out-Cf-Service Well O Out-Of-Service Well Renewal ❑ Cross-Connection Repair DEC 3 O <br /> _ New Pump 11 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing 2� <br /> WELL CONSTRUCT16N )- N 104QUIN CO <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool [I Push Point ❑ Other ENVIRO UN <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gravel Size EFJA,tf r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth It ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mbrR gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions-Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP q'Submerzible❑Turbine ❑ Other HP .' '4-' 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 ofany water wells or surface water within 200' radius ofproposedwell. <br /> .:11DI'D iul :...-H-0111i�Sl�vt-i!"CE 1 tiff E ACEI' 3'<iSta11IRLI FOR LYJTPEZ.HG�- --: SE C.--ii L(2,39) Ju-f Ul! <br /> l DEPARTMENT USE ONLY <br /> Appncatlon Accepted sy v Date a 30 jW Area V/CI� Employee ID# a� <br /> Grout Inspection By Date ❑ SPECIAL_Well Permit <br /> Pump Inspection By ,�', Date 'LZM4 A)7-023 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Nee Well Itj=y3�$ y3gJ y3ga sGmalfir►a <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into C sh Remitted Service Request# <br /> 3 o osl 7r I4•30 a <br /> tMD043-0610123rz021 7 / _ J� /����„ / Pageroft Wen/Pump P=r <br />