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1 �� WELL/PUMP PERMIT S TAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NODI-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED l� f r CITY/ZIP L C cl (JOB ADDRESS C1{h C m (CROSS STREET I C A V) Z17 APN Q _QJ PARCEL SIZE �2.(p -_LAND USE APPLICATION# OWNER NAME T r)C1-e'r�� ' { ^ h PHONE �'`) OWNER ADDRESS `/c• GTYISTATE/ZIP_ / --y_ CONTRACTOR Vttt l V��t Il { ^ ) (l-PHONE 26,'1 CA / CONTRACTOR ADDRESS p C �1 C, —� ,� _ CITY/STATE/ZIP �/ C i S y.;J r2 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ,LICENSE C-57 C-61 D-09 Other NUMBER �'+,l t 3 'Ss EXPIRATION DATE / DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) !INTENDED USE QomesticiPnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam plinglCharacterization - Public Water System If different from Owner Water System Name Contact Name or Phone Number `TYPE OF WORK "y New Well )(Replacement Well Well Alteration/Modification OtherQr� e • Monitoring Well(s) #of wells Soil Bonng(s) #or borims Geotechnical #of borings C V/1 iAb Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair J� C New Pump__— Pump Replacement Pump Repair Raise Well Casing _ �D WELL CONSTRUCTION Sq 23 Drilling Method )(Mud Rotary Air Rotary Auger Cable Tool Push Point Other HE N/ QU/ CpV Proposed Well Depth L,!• ft Excavation in diameter Open Bottom )k Gravel Pack,Gravel Size_ _ AtrT�Rd NTq N7Y Conductor Casing in diameter t Conductor Casing Depth ft q TME Well Casing Diameter in Thickness/Gauge/ASTM Sched C D Steel A Plastic Stainless Steel Other NT Grout Seal Depth ft Neat Cement(94 lb bag/5-f0 gal water) A Sand Cement ) l 5 sack mix17 gal water Bentonite(20%solids) Other Grout Placement MethodPumped Free Fall Other i—Y Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor Other - Concrete Pedestal Dimensions.Width S ft Length ft Thick �tn Christy Box Stove Pipe PUMP 2�Subrnersible Turbine Other HP Pump Set—YS It Standing Water Level Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two propertN lines. For Domestic. Agriculture,Industrial well,provide location of an} water wells or surface water within 200'radius of proposed well. D P A R T M ENT U S O N L Y Application Accepted 8y Dale ll � Area Employee IDS Groul Inspection By Date ^Zr SPECIAL Well Permit Pump Inspection By Date — —2 WAIVER Received + Soil Boring Ins ection By _—_ Date ConstructAAMde ell Depth .iG� ft COMMENTS . /ZL'Q� ( � PE SC Received Check#% Amount Permit/ Codes 1 Info Bv CarAh emitted Date Service Request# invoice# Well ID# !' 7 R 314 V I _ v2 I Nk* ,� ��dl Yurrp?P�znw