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. . EMAILED <br /> _VWAQ� <br /> � rrrL�Ilrrvmr r II_I�wl� I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 • (209)468-3420 <br /> NON-REFUNDABLE PERMIT ytJ CALL(209) <br /> 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR ,FnR'Or�/tM DATE ISSUED <br /> JOB ADDRESS 1 1`� CITYIZIP f 1 1D0y 41JF W W N <br /> m <br /> CROSS STREET 1 APN1'Z ✓+ U'0/ PARCEL SIZE Z�LAND USE APPLICATION#I'I11 M <br /> fri <br /> OWNER NAME pq� V LP CCU <br /> Y "v PHONE �/'I'J V (� go,�Jn� y <br /> OWNER ADDRESS 1 12- /Vv ,1 e' CITY/STATE/ZIP M �GWr <br /> CONTRACTOR ,AS �yv I I N IV '*`IA11PHONEEy� ✓/�� �'l�-V <br /> CONTRACTOR ADDRESS 1�a 1` I1/v S CITY/STATEIZIP 1�'`V�Q/ W. q �� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 C-61 ❑ D-09 Other NUMBER EXPIRATION DATE / <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private rrigation/Agricultural Industrial Water Quality Monitonng L Sod Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well ❑ Well Alteration/Modification - Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of bonngs <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> C: New Pump Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method".Mud Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth fl Excavation -n" in diameter I, Open Bottom V Gravel Pack/Gravel Size in diameter <br /> n Conduct r Casing in diameter / Con for g Depth /� ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede Cl Steel Plastic Stainless Steel Other <br /> Grout Seal IN OkI <br /> ft P. Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) U Other <br /> Grout Placement Method*Limped Free Fall l Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Dnller Pump Contractor Other PAY�E <br /> Concrete Pedestal Dimensions:Width ft Length fl Thick Qj (-PIVED <br /> in Christy Box f Stove Pipe <br /> PUMP fl Submersible Cl Turbine ❑ Other HP Pump Set ft Standing Water L ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followin Ppips N-'% <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing we s�'1 1,.- ►tFE3, <br /> potential sources of contamination, sewers or private disposal systems. include distance from two property linesAor Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> �1l`IJIC NI.14 1101.R ADN AN(L NO LICE Rk.(2[IRL:D 1-01k)Il I SSPLCI IONS-I'LLASL GILL(209053-76,97 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ( D�2 Area �� Employee ID# <br /> Grout Inspection By. . Date iZ % Gi L SPECIAL Well Permit <br /> Pump Inspection By Date <- WAIVER Received <br /> Soil Boning In Ction By /Date/ Constructgd.,Well epth R <br /> COMMENTS �l R.�1r1L /t.�.�iNr'ltit:�' S GI 1>Z D RA-w L �yG� f WL <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info aw qash Remitteck Service Request <br /> 1 - S• 3 <br /> ��a3�� ;�3 <br />