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EMAILED <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT,-,.�j� (�� 'CALL(2209 953-76977 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS il�SG "SWION FIC1101A r`1 �GILION, C4 I�-32-0 m <br /> CITY/ZIP <br /> j� ( D <br /> CROSS STREET �� ^ APN 201- 030_ O t V PARCEL SIZE LAND USE APPLICATION�f <br /> _ m <br /> OWNER NAMErAU(IA 1' � PHONE l \ N <br /> OWNER ADDRESS %! w,V t '1 tjPA CITY/STATE/ZIP <br /> I <br /> CONTRACTOR I> N V PHONE <br /> CONTRACTOR <br /> ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP r <br /> LICENSE G57 C-61 D-09 Oche' NUMBER EXPIRATION DATE - <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private _ Irrigation/Agricultural Industrial F1 Water Quality Monitoring .-_ Soil SamplinglCharactenzationY <br /> ^1 A <br /> - Public Water System I IEN <br /> If cifferent from Owner Water System Name Contact Name or Phone Number V 1 E <br /> TYPE OF WORK New Well Replacement Well I1 Well Alteration(Modification F Other D <br /> Monitoring Wel(s) #of wells SoilBoring(s) #otborinys Geotechnical kot[xK N ,? <br /> Out-Of-Service Well Out-0f-Service Well Renewal L Cross-Connection Repair S o2� <br /> New Pum Pum Replacement PumD Repair r Raise Well Casing SAN JogQ <br /> 'WELL CONSTRUCTION Eq�T NhgE UNTy <br /> Drilling Method)�'MLid Rota(y� Air Rotary Auger Cable Tool Push Point Other DFp R MENT <br /> Proposed Well Depth�ft Excavation _in diameter Cl Open Bottom ( Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter�k_ in Thickness)Gauge/ASTM Sched M0 G Steel Plastic Stainless Steel Other <br /> Grout SealDepth 1�Q ft Neat Cement(94 Ib ba915-10 gal wafer) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped - Free Fall Other D Retardant I Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor ❑ Other <br /> Concrete Pedestal-Zimensions:Width it Length ft Thick <br /> �in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water Nell with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water hodies 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"ells or surface Nater within 200'radius of proposed Nell. <br /> vtlll�Il <br /> NJ:4 1101.R AD\'AN'CE NOTICE REQ1 IP I i tR(\tiff t 1 It r'.�-PLF kS} ('U.1.12('ri <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 4 (111 )-4 Area C2° Employee ID# <br /> Grout Inspection By Date 3/19 z4. _7 SPECIAL Well Permit <br /> Pump Inspection By Date a WAIVER Received <br /> SotIB oring Ins on By Date Constructed Well Drpth R <br /> COMMENTS k d uu� N1• L t i. ,- <br /> �•{. �z 4 f>1 k C-x wu L 6 <br /> 11— JL 0 PeLA-4K <br /> PE SCI Received C eck#/ Armbunt Date Permit/ Invoice# Well ID# <br /> Codes Info B h Remitted Service Request# <br /> 5k-S0 i LVJPA)415 EN <br /> xr t r <br /> EHDe43J%"f,7202-1 t'alrr 1 ut' W 11 Pump P—it <br />