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I <br /> I <br /> EMAILE <br /> 8 >5 a-0— <br /> ■ etrV�r�r Vmr r r..r�rnr r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 7—t2l(A F 0 IM) M� CITY/ZJP t;S 0 WON c a l 2-D <br /> � <br /> Seg ,�,� 2�� -zao-zoo 1� <br /> CROSS STREETy7�Y �{'�p /J APN PARCEL SIZE LAND USE APPLIC/�/A7TION# En <br /> z <br /> OWNER NAME lJ 1 I �� I! l�� (/� PHONE I J 4 l m <br /> OWNER ADDRESS G 4 r a q '1WCrrY/STATE/ZIP <br /> n '/nom �'/}/ <br /> CONTRACTOR OI II} S n /J^I MPHOONEyn,( /},/✓� r/�IgZ I/ <br /> CONTRACTOR ADDRESS I I y 11 J f/t/ 1 (/1 CITY/STATE/ZIP J//o tel/.l 1 V `"t qg- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 IC-61 D-09 Other NUMBER U22 EXPIRATION DATE 1 ✓ o �� <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> Iq <br /> INTENDED USE Domestic/Private ' I rngati on/Agri cultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ublic Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well eplacement Well 0 Well Alteration/Modification i. Other <br /> Monitoring We�Is)' <br /> #of wells ❑ Soil Boring(s) a°t borings Geotechnical a of borings <br /> Out-Of-Service Well LI Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement U Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method MudRotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth _ft Excavation it„ in diameter Open Bottom X Gravel Pack/Gravel Size, in diameter <br /> - Conductor Casing in diameter i Conducto Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched f-01) Steel Plastic 1 Stainless Steel i'. Other <br /> Grout Seal Depth 2,0U it Neat Cement(94/b bag/5-10 gal water) i, Sand Cement sack mix17 gal water <br /> `Bentonite(20%solids) C Other <br /> Grout Placement Method Pumped i_1 Free Fall _; Other Retardant/Accelerator(name) PAYMENT <br /> PEDESTAL Installed By '_1 Driller Pump Contractor Other <br /> Concrete Pedestal :Dimensions:Width It Length ft Thick Al 1P I A 901 <br /> Christy Box Stove Pipe <br /> (PUMP Submersible.. Turbine Other HP Pump Set ft Standing Wgte'1+!-pJvoi+'-•�- 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 of any water wells or surface water within 200' radius of proposed well. <br /> �IININJt NI-'f IIUL It XI)\ L:N0I ICI_REQJ IJRJ.If I()It INNI't:( I IONS-1't.E.1Jt.CALL(209)1, <br /> DEPARTMENT US7 O LY _ <br /> 1 <br /> Application Accepted By Date Area� C � � � � Employee ID# <br /> Grout Inspection By Date (? _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins�.on By Date Constructed Well Depth L" ft <br /> COMMENTS rJC/t'`C'Tc/Z 'c`��� 4'. <br /> J� ir�PySc.l•Z�.�. <br /> PE SC Received Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B C Remitted Service Request# <br /> L' <br /> y3 C j z 1£ tb19123 wt?o>(P X41 -; l41A <br /> -Iv 21-,3 <br />