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1 EMAILED WELL/PUMP PERMIT <br /> SAN JOAQI nu CDJ(K Y RONMENTAL 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 /> w <br /> Joe ADDRESS McbylCrrY/LP <br /> CROSS STREET APN PARCEL SIZE • LAND USE APPLICATION# a <br /> m <br /> OWNER NAME V! PHONE �i�'j/,n e1 <br /> OWNER ADDRESS jj CITYISTATEIZIP w1 i l l VGl ��i "/ W <br /> CONTRACTOR II1 I wo. PHONEAA ZC, <br /> �� 1�G�� <br /> CONTRACTOR ADDRESS t CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP rA <br /> LICENSE C-57 C C-61 D-09 ❑ Other NUMBER U u Z ExPIRATION DATE N <br /> DOMESTIC WELL SAMPLING:)(General Mineral/Coliform Bacteda(4391),I(Dibromochloropropane(4392))(Arsenic(4393) <br /> INTENDED USEDomesticlPrivate F1 Irrigation/Agricultural ! Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Afteration/Modification 17 Other <br /> " Monitoring Well(s) #of wells El Soil Boring(s) <br /> N of borings ❑ Geotechnical If of borings <br /> Out-Of-Service Well 71, Out-0f-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement 0 Pump Repair Il Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodud Rot Air Rotary ❑ Auger n Cable Tool ❑ Push Point fl Other <br /> Proposed Well Depth _ft Excavation ���in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter UL in Thickness/Gauge/ASTM Schad 0 Steel ❑ Plastic ❑ Stainless Steel L Other <br /> Grout Seal Depth I V ft U Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> '118entonit (201% solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 11 Pump Contractor ❑ Other RECEIVE <br /> F Concrete Pedestal LDimensions:Width ft Length ft Thick <br /> in L Christy Box ❑ Stove Pipe UL I <br /> PUMP L Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level SAN JOAOIIINC L <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following IYftigp,VP `Nr <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 /> ,NIINIMUNI 24 1100 R,\DVANCE.14O I WE REQLIRED FOR INSPECTIONS-PLEASE CALL(2119)9,3-7697 <br /> EPARTMENT UrE pNLY �j <br /> Application Accepted By Date Z 1-� Area ✓ q01Employee ID#� <br /> Grout Inspection By �. Date L SPECIAL Well Permit <br /> Pump Inspection Date L WAIVER Received <br /> Soil Boring Inspection By Date' Constru Well Depth v ft <br /> COMMENT /VO- the ret; d T <br /> I <br /> PE SC Received Check#1 Amount I Date Permit/ Invo Wall 1D# <br /> Codes Info A EW Remitted <br /> y Service Request IF <br /> Gam'' 17A VS <br /> 2 <br /> �3 a- <br /> P�oft p',el�Puv4 PumA <br />