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EMAILED <br /> 8 >sa3.O <br /> i •er✓L-ur VIYIF <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7X7 1 0�q I,LQ/ � fSGr�101�1 cl �53Z0 so <br /> m <br /> JOB ADDRESS CITYZP m <br /> Dp p�- P J Zit 2 0-Z�10 D <br /> CROSS STREET sVY�dnl��('JY 1''�yt'/'J7�/JJ1. APN � � PARCEL SIZE LAND USE APPLICATION#Li�j. <br /> En <br /> OWNER NAME r/1 ' A'V f' �,a (j 1, PHONE �1 1 m <br /> OWNER ADDRESS 2 (' CITY/STATE/ZIP CN M O N' C / q-32- <br /> - 2—O <br /> CONTRACTOR V Y61nPHOONEEWZ2- - lq2, <br /> CONTRACTOR ADDRESS M CITY/STATE/ZIP 1no ✓ r to `" g3%7 <br /> N <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STA <br /> ITnuE/ZIP G,'}} 7 <br /> LICENSE C-57 H C-61 D-09 E Other NUMBER V 2Z ExPIRATION DATE I v� <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliforrn Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEDomestic/Private Imgation/Agricultural Industnal 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 x Replacemert Well i7 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells D Soil Bonng(s) #of bonngs Geotechnical a or borings <br /> L Out-Of-Service Well U Out-Of-Service Well Renewal Cross-Connection Repair <br /> fl New Pump Pump Replacement U Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota Air Rotary Auger I Cable Tool _ Push Point Other <br /> Proposed Well Depth (Obft Excavation I t 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 ThicknesslGauge/ASTM Sched '0D Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 2,00 ft r, Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> �Bentonite(20%solids) L Other PAYMENT <br /> Grout Placement Method I Pumped O Free Fall J Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor _ Other <br /> Concrete Pedestal 17Dimensions:Width ft Length ft Thick <br /> �in E Christy Box Stove Pipe <br /> PUMP D Submersible:.' Turbine Other HP Pump Set ft Standing Wt3V"" ft <br /> I'I ltk 111 NEIN11fAE1CT- <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, prop"- 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 /> V IN1 NII,NI 24 1101.R ADVANC I:NOTICE REQUIRED FOR INSPECTIONS-PLEASE C'ALI.(209)953-7697 <br /> DEPARTMENT US O LY <br /> Application Accepted By Date 7/� YZArea 5_ � 9 Employee ID# C <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received? ( <br /> Soil Boning Ins 'on By Date Constructed Well Depth <br /> COMMENTS cl'ZL 6,rtl( Q i"C?�¢t l•Z�i�. <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice* Well IDO <br /> Codes Info B emitted Service Request# <br /> q3 7c 1 GI -L Z-D tb1R123 �.aPmaP�{y�4�k <br /> 39/ IT la 2"1 <br /> 37 to N 4 0 <br /> 1v 2-3 <br />