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03/0/11093 S° WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT_ CALL(2y.0�9 99`5j3�-7697 FOR INSPECTIONS 1ElXlPIIRt ES/1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS 1 1 Vw "1 CrrY21P {/�)1V (a q / / �7' t;i <br /> CROSS STREET APN D PARCEL SIZE_J� OLAND USE AAPPLICATION#/7J <br /> OWNER NAME PHONE <br /> OWNER ADDRESS -1CITY/STATE/ZIP I (A nI ftcA q% ��7 <br /> CONTRACTOR 1 gyp' (I 11�/ PHONE 1r���/�/ �vrv� G 7 <br /> CONTRACTOR ADDRESS I 1 I V CITY/STATEIZIP�d /J! t/ COVO q /�1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STi'Ap1TEIZIP <br /> LICENSE 11c__57 C-61 D-09 Other NUMBER V 2:2_ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)r--Arsenic(4393) <br /> INTENDED USE DomesticlPrivate gation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization Aq <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well ❑ Well Alteration/Modification Other 4 FV •O <br /> #of bony, s #at bori 2v, <br /> _ Monitoring Well(s) #of welts ❑ Soil Boring(s) 9 Geotechnical J <br /> Out-Of-Service Well LJ Out-Of-Service Well Renewal Cross-Connection Repair SAty JO 023 <br /> New Pum a Pum Replacement - Pum Repair <br /> Raise Well Casing ESV q Q(/ <br /> WELL CONSTRUCTION TN pFpME 1 <br /> VNT. <br /> Drilling Method �v1ud ❑ Air Rotary Auger __ Cable Tool Push Point Other qR <br /> Proposed Well Depth_)1ft Excavation , in diameter Open Bottom Gravel Pack/Gravel SizeAt V <br /> in diameter ENT <br /> ❑ Conduct r Casing in diameter / Conduct r asing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal XBentonite <br /> th ft L' Neat Cement(94 Ib bag/5-10 gat water) Sand Cement sack mixf7 gal water <br /> (20%solids) ❑ Other <br /> Grout Placemethod umped ❑ Free Fall ^ Other Retardant/Accelerator(name) <br /> FPEDESTAL Installed By J Driller !-.; Pump Contractor ❑ Other <br /> E, Concrete Pedestal[,,Dimensions:Width ft Length ft Thick <br /> in C Christy Box D Stove Pipe <br /> PUMP ❑ Submersible'_!! Turbine "-1 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. 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 /> MINIMUM 24 HOUR ADN'AYCE NOTICE REQUIRED FOR INSPECTIONS-M.F.ASE CA11.(209)"3-7697 <br /> DEPARTMENT U E (NLY p <br /> Application Accepted By Date 3b 4 <br /> 23 Area S Employee ID# F2 <br /> Grout Inspection B �� Date' `(�^,��\ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS �/�// �; 1e /V- 7- 2-47 ��vx 4,1!11e1n1 cX�e�a>� /2µrt�,h <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service R nest# <br /> /ro -3/.3-/23 DOS/ 3 <br /> EIiD611460W7/1_022 �/'�� ^�/������� Pap 1 ort w'cll!RuvPrnnit <br />