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VVtLL/rumr rF-n1a11 <br /> ON AVENUE-STOCKTON CA 95205 (209)469-3420 <br /> StiN&AC,u!,J COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 EAST HAZELT <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N <br /> JOB ADDRESS �' fV 11 IZ 17 _ CITY/LP t v <br /> I Y 7— I Q Y PARCEL SIZI LAND USE APPLICATION# O <br /> CROSS STREET �N w — <br /> �?� 1 715 - <br /> rn <br /> OWNER NAME �A M L Lit r r e Y G <br /> PHONE � � <br /> OWNER ADDRESS s <br /> CITY/STATE/ZIP �,A LL V,-tom.n 1 c c\ �C <br /> ��� W�� <br /> n c PHONE a1 UC �G_ , i <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS C- j <br /> O 1�C�X -4L� CITY/STATE/ZIP _ \ � ` <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR ADDRESS l <br /> LICENSE ';AC-57 i C-61 i D-09 -i Other <br /> NUMBER JC < </ EXPIRATION DATE 7 -.3 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )4,Domestic/Private '1 Irrigation/Agricultural "1 Industrial ? Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System Contact Name or Phone Number <br /> If different from Owner: Water System Name <br /> TYPE OF WORK /.New Well 7 Replacement Well ❑ Well Alteration/Modification Other #of borings <br /> 7 Monitoring Wells) #of wells ❑ Soil Boring(s) <br /> a of borings -1 Geotechnical <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum i Pump Replacement ❑ Pump Repair Raise Well Casing <br /> rWELLCONSTRUCTIONthod Mud Rotary Air Rotary Auger ❑ Cable ToolPush Point OtheWell epth ft Excavation �2— in diameter :, Open Bottom Gravel Pack/Gravel SizeI/ in diameter <br /> Conductor Casing in diameter / Conductor Casing DepthC( 7 Steel Plastic - Stainless SteelOthersing Diameter� in Thickness/Gauge/ASTM Sched C� * <br /> Grout Seal Depth �Cc ft 1 Neat Cement(94 lb bag/5-10 gal water) ,Sand Cement s -7 sack mREC <br /> -i Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall -i Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ft Len tri ft Thick r' ""E"IRO ""N <br /> :� Concrete Pedestal .Dimensions.Width 9 —, ,,,L <br /> in ❑ Christy Box Stove Pipe <br /> PUMP _ Submersible"' Turbine Other <br /> HP J Pump Set ft Standing Water Levei - 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 any water wells or surface water within 200' radius of proposed well. <br /> JilNiMUM 24 iiOUR AD%"A\k b.N01ICE REQLiRED l•OR I..\�SNECI IO\J-}'LLA56 CALL(209)953-7w)-17 <br /> DEPARTMENT USE ONLY <br /> 4, „7�,1 Area rig� Employee ID# <br /> Application Accepted By `— f J`� Date <br /> Grout Inspection By <br /> �,, ,", Date .a 7_.?r<�2- SPECIAL Well Permit <br /> Pump Inspection By Date c�tifl�� WAIVER Received <br /> Date Z� Constructed Well Depth ft <br /> Soil Boring Inspection By t <br /> COMMENTS t r('� h+'r' F SPS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted ervice Re uest# <br /> I <br /> X13?C) J <br /> 1-1 IlkF i I C, 2- <br /> Ll 3 <br /> "y3 �6)O <br /> well Pump Perm,[ <br /> EIIIw43-0604,10712022 1 y qq �� �2 Pag ore 'I 2 <br /> ! f / 6�7i/'�j 7i� tfCb <br /> l <br />