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(f7r�cv c�,�i 1Lb�vis s ; ( 4 6 p 5 3 r�-►1r(a.to �-u-� 11' 14-r� ��5-0a,o z � � <br /> t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> !JDDRESS 12-2-0 V7 NNANA A-VV a-ay 02ti4a <br /> OBACr"1ZtP ff41QN ja 11�32-0 M <br /> CROSS STREET fthA ZO AP Y -144 PARCEL SIZE IL-Z L LAND USE A'PPPLLLICAT1InON#(,� (/J�,'G a <br /> OWNER NAME '� 1 MaNbl_ PHONE 1 V { �Y (\- 1 V l 0- m <br /> w <br /> A1,I ^ 1 to <br /> OWNER ADDRESS 'V 1`� ' �+ CITY/STATE/ZIP <br /> CONTRACTOR MQ �P I I IS Dril l)Nq Nu PHONE 7•✓�n AAA <br /> �n <br /> CONTRACTOR ADDRESS <br /> HA� I• ey I� <br /> J ' CITY/STATE/ZIP M�1 E� �)V\ li%N—1 <br /> NSUBCONTRACTOR 1� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 02 <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION ��11ON DATE ` 1 Z S <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private Irrigation/Agricultural I_ Industrial U Water Quality Monitoring ! Soil Sam pling/Characterization <br /> Public Water System <br /> �- It mt'erent arum Owner Water Systrm Name Contact Name or Plane Number 1/� <br /> TYPE OF WORK New Well Replacement Well I l Well Alteration/Modification L Other <br /> Monitoring Well(s) #of wells ❑ Soil Bonng(s) #ofbonngs LI Geotechnical �f�a TJ X23 <br /> Out-Of-Service Well i I Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> New Pump Pump Replacement '-; Pump Repair L Raise Well Casing <br /> ti A�TyR�N �C <br /> WELL CONSTRUCTION ,qR �NTy <br /> T <br /> Drilling Method Mud1 Air Rotary Auger�l Cable Tool Push Point Other NT <br /> Proposed Well Depth-M. <br /> epth o _ft Excavation J{- in diameter Open Bottom y Gravel Pack)Gravel Size in diameter <br /> Conductor Casing in diameter / Conduct r asing Depth It <br /> Well Casing Diameter n in Thickness'Gauge'ASTM Sch( Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_iW. ft u Neat Cement(94 Ib bagiSfC gat water) Sand Cement sack mix17 gal water <br /> Bentonite(204;solids) C Other <br /> Grout Placement Method,)QPumped :: Free Fall Other Retardant/Accelerator(name) <br /> PEMSTAL Installed By Driller Pump Contractor I. Other .._ <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick +. <br /> lin Christy Box Stove Pipe <br /> PUMP Submersible Turbine : Other HP Pump Set ft Standing Water Level <br /> Plot flan 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, strut' res,, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Dom res,,' <br /> Agriculture. Industrial well,provide location of ani,water wells or surface water within 200'radius of proposed well. <br /> %II's1%11'\1 14 IlOt 1(. 111.1tiCt:-%Oil( t RE01 1RED I('!, ':ASE CALL 12ii'i = '� <br /> DEPARTM ENT USE ONLY Q <br /> Application Accepted By 9 y"W— Date 6 �-3 Z/ Area f E'er L Employee ID# �- <br /> Grout Inspection By lLn Date (,,,l(ZSPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By �� Date Constructed Well Depth tt <br /> COMMENTS -D trv� ik �Ir -LY- 64' uJ A'V- �v> 4 <br /> PE SC Received ChecldN Amount Date Permit/ Invoice# Well IDX <br /> Codes Info ev, gash Remittecl, eryice Request# <br /> J J o l 11 WW I Ll <br /> EtflxN}Ob OtA7rM22 � _ /1 Pagelof2 Nell 1'u, .Panu: <br />