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EMAILED�1 WELL/PUMP PERMIT <br /> SAN JOAQUIN '5VI ( t g�AL(T2�l, '.TMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PlfRMIT \ CALL(209)953-7697 FOR INSPECTIONS EXPIRES/1 YEAR FROM DATE ISSUED <br /> .108 ADDRESS t 'l 1 / Vt 1 h V CITY21P 1—C i 1 4� m <br /> l <br /> CROSS STREET "�1 I\O f n C I1' +17- APN ��C� �' L't `� PARCEL SIZE I -� LAND USE APPLICAATION# <br /> OWNER NAME � t A <br /> \�C r►c ( PHONE �k(f7 .1� (W �7– 7 m <br /> �Q `` 2 <br /> OWNER ADDRESS \1 �0 7G. 27Z 7 CITYISTATE/ZIP Lodi c75yf 1�) <br /> CONTRACTOR �jl�I C. L� 1 t n 4 PHONE :� C /� ��C.- ,9 – _^7Zq <br /> CONTRACTOR ADDRESS C c CITYiSTATE/ZIP C_ n)L l ""t "i J K' �✓` <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >(C-57 C_61 _ D-09 Other NUMBER,/ `f 1_).J_) EXPIRATION DATE 7- <br /> DOMESTIC <br /> -DOMESTIC WELL SAMPLING:/,General Mineral/Coliform Bacteria(4391)ADibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 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 Weil Replacement Well Well Akeration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) itof bonngs Geotechnical rof bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)�Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation _ in diameter Open Bottom I/Gravel PackiGravel Size 1A " in diameter <br /> Conduct r Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedCl Steel X Plastic Stainless Steel Other <br /> Grout Seal Depth .SLY—. ft Neat Cement(94 1b bag/5-1 D gal water) /'Sand Cement I t'.3 sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 7kPumped Free Fall Other Retardant I Accelerator(name) <br /> !PEDESTAL Installed By X Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 2_ft Length�_It Thick G It <br /> in . Christy Box Stove Pipe <br /> !PUMP 1t Submersible Turbine Other HP ( '/ Pump Set ;�] ft Standing Water Level L,C: 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 anv water wells or surface water within 200'radius of proposed well. <br /> D PAR T M E N T U E O N L Y Q <br /> Application Accepted By Date 5 Area ! Employee ID# <br /> Grout Inspection By Al Date 6--3-7-3 SPECIAL Well Permit <br /> Pump Inspection Bys_ir� Date Z—/Z-2-9( WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth Zqs ft <br /> COMMENTS T: 3 JJ• G-I JSZ �_-'V-3s,dZ <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info 8 Cash emitted Date Service Re uest# Invoice# Well ID# <br /> $2AvOD 10 <br /> 9/ isS I <br /> q2 _ 7(o - <br /> Y316'O os'i Seo 0 D <br /> I HLNHI i.Ub U10-.n_3 1'x�!c I ,..: V�J� p Pram, <br /> C (QU025 I 01? D 500 0 <br /> 3 <br /> JY4 jR7&0,V,IN COU 2 <br /> T hpF ife ry <br />