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EMAILED <br /> Cn� <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 <br /> //�PERMIT t�� �p CALL 22009 953-7697 FOR INSPECTIONS �Q EXPIRES 1 YEAR FROM <br /> f DATE ISSUED <br /> LA <br /> JOB ADDRESS 1""00001 1 A \ALA t R r�� Crry/LP f l VV N CA I G 3IS,V 4 <br /> CROSS STREET U A w 1,V APN 29[; - 1'g O- 010 PARCEL SIZE 1�LAND USE APPLICATION# - A <br /> m <br /> OWNER NAME �T11110\ 'yll 1 Illy PHONE <br /> OWNER ADDRESS SIJ v�+1 . • `���tw�1 V t'111("/` CrTYISTATE/ZIP <br /> CONTRACTOR Mkn 1d1+� Q �1 I rV r 11V v rPHONE <br /> CONTRACTOR ADDRESS I q f I V S CRYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ! C-57 ._! C-61 _ D-09 Other NUMBER UZ EXPIRATION DATE ;/NQ.2G, <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural '- Industrial ❑ Water Quality Monitoring _- Soil Sampling/Characterizatio� <br /> .i Public Water System <br /> If aiflerent from Owner. Water System Name Contact Name or Phone Number / A <br /> TYPE OF WORK XNew Well Replacement Well ❑Well Alteration/Modification n Other 4J <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings _ Geotechnical_ #of tori / <br /> Out-Of-Service Well ❑ Out-0f-Service Well Renewal ❑ Cross-Connection Repair '104 <br /> -New <br /> QlJ N 7 <br /> New Pum Pump Replacement ❑ Pump Repair = Raise Well Casing HP , <br /> WELL CONSTRUCTION DE"v /v NT y <br /> R <br /> Drilling Method tpth <br /> Mud Rot ry Air Rotary n Auger Cable Tool Push Point Other T/tir /VT <br /> Proposed Well 1�ft Excavation & in diameter Open Bottom Gravel Pack/Gravel Size_in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 110 in Thickness/Gauge/ASTM Sched 200 ._ Steel NPlast c Stainless Steel -- Other <br /> Grout Seal Depth2.00ft Neat Cement(94 Ib ba915-10 gat water) S Sand Cement sack mix/7 gal water <br /> xBentonite(20%solids) Other <br /> Grout Placemen' <br /> M-ethod' Pumped _ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor 7 Other <br /> Concrete Pedestal -Dimensions:Width ft 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 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 /> N11NUNILT.N1 24 IIOLR ADN ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)94:•-7,,'I- <br /> DEPARTMENT USfE O LY p <br /> Application Accepted -:�- Date Z/ �� 2 Area // Employee ID# <br /> Grout Inspection By 1V460671 Date _y4-/Z q ❑ SPECIAL Well Permit <br /> t <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection B Date Constructed Well Depth ft <br /> COMMENTS 6), 2 -c 7 .c:> > f7Cc,. �L_ .7 1 I 1 S ,, C I <br /> I r,� /j ao c' <br /> PE Sc Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitt-led Service Request# <br /> r:}ID,?11-IM 04'07r?02. �� '� /������ Pap<I of� Nc�l-r�„�r Y:r:,,n <br />