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E 1 ED <br /> r WELLIPUMP PERMIT <br /> SAN JOAQUIN CUNTY E"oNMELTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS ✓ 1 V 1 CITY/ZIP m <br /> V% <br /> D <br /> CROSS STREET ' 1� AP � PARCEL SIM USE APPLICATION##[j��}� <br /> �4J /V t ✓ 1� m <br /> OWNER NAME IV edo 10 PHONE � <br /> OWNER ADDRESS JAZZ sc, I yTIP-Mo V Me/- CTY/STATEIZPpm�0f,t r FI-0� y <br /> CONTRACTOR 7� U �APHONE [ i <br /> CoNTRAcTnR ADDREss I CITYISTATFMP t I 1 rA <br /> i. SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ti CITYISTATFIZIP <br /> 7. <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ dftr' NUMB& V"Y EXPiRATION DATE <br /> DOMESTIC WELL SAMPLING:rGen6rat Nlin&al/CoGform Bacteria(4391)rDibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE DomesOdPrivate 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If ck ferert hum owner. Water System Name Contact Name or Phone Number <br /> TYPE OF Wows New Well ❑ Replacement Well 0 Wes AlterationlModification ❑ Other <br /> 0 Monitoring Weft(s) #of walls ❑ Soil Boring(s) #°'b°r1n9, ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casi <br /> WELL gON§MOZ <br /> Drilling Method)Mud Ro ❑ Air Rotary 0 Auger El Cable Tool ❑ Push Point ❑ `Other <br /> Proposed Well pthit Excavation _ I in diameter ❑ Open Bottom �Gravel Pack/Gravel SizeA 10 in diameter <br /> 0 Casing in diameter / Cond sing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/AST Sched ❑ Steel Plastic ❑ Stainless Sleet O Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement M od Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) f`d7 <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor C Other <br /> 0 Concrete Pedestal❑Dimensions:Width It Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible0 Turbine ❑ Other HP Pump Set ft Standing W <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 /> ti ,.'.S. => i::. _ 1€r E`•,. '�i;i i t: 6{€�E€fi.:i!. .;k 3` t,. ".<?" t.t F ..'Ll. .:.8�i. <br /> DEPARTMENT US O LY <br /> Application Accepted By _ -- Date /< ZZ— Area Employee l <br /> l� i <br /> Grout Inspection By '� � i -c- Date E ' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Parrnit/ Invoice# Well IDN <br /> Codes Info By Cash Remitted Service Request <br /> ,1ru 2 <br /> EHDN3-06 IW34702I 1 r�' 2—SZ 3 3 5 3 ��L WcII,P—V Pcnnt <br /> L <br />