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E-MAILED <br /> EM <br /> 1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS O r 1 CITY/ZIP m <br /> CROSS STREET 1•IO 1V W�A 1' y\' APN 1 00—2,10 PARCEL SIZE L5 LAND USE APPLICATION# A <br /> m <br /> OWNER NAME 41, M �1 N N10 PHONEoq a-71. <br /> OWNER ADDRESS CRY/STATE/ZIPy ci 14 <br /> CONTRACTOR I IN PHONE L/ ( D, 24 <br /> CONTRACTOR ADDRESS I610L CITYISTATE/ZIP ymbmr! <br /> J I <br /> SUBCONTRACTOR 1 lk PHONE <br /> SUBCONTRACTOR ADDRESS l{CITY/STATE/ZIP <br /> LICENSE C-57 L, C-61 :: D-09 - Other NUMBER�lI MU EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:)OGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 0 ADomestic/Private - Irrigation/Agricultural :: Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization /1 <br /> 0 Public Water System ^ <br /> If dr. `N <br /> different from Owneater. System Name Contact Name or Phare Number - V cr <br /> TYPE OF WORK New Well Replacement Well D Well Alteration/Modification ii Other CD <br /> s k of bon <br /> ❑ Monitoring Well(s) #of wells ❑Soil Boring #ofBonns) 9 Geotechnical / <br /> D Out-Of-Service Well u Out-Of-Service Well Renewal Cross-Connection Repair SAN <br /> ❑ New Pump Pump Replacement 0 Pump Repair Raise Well Casing Oq Q <br /> WELL CONSTRUCTIONATN 41 7-Y <br /> ��NTY <br /> Drilling Method*Mud Rotary Air Rotary Auger Cable Tool L Push Point Other f`�ENT <br /> Proposed Well Depth ft Excavation J\' —in diameter C Open Bottom = Gravel Pack/Gravel Siz ' in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing D ameterin Thickness/GaugerASTM Sched '�� Steel Plastic Stainless Steel Other <br /> Grout Seal DepthAgft C Neat Cement(94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> lf'Bentonit,(20%solids) ❑Other <br /> Grout Placement Method Pumped L Free Fall 7 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller - Pump Contractor ❑ Other <br /> D Concrete Pedestal _.:Dimensions:Width it Length ft Thick <br /> �in 0 ChristyBox Stove Pipe <br /> PUMP 0 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 Nater within 200'radius of proposed well. <br /> MININIUM 23 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PILE'LSF CALL.(109)953-7697 <br /> DEPARTMENT U E O/y LY LflQq <br /> RL <br /> Application Accepted By_ Date 3�1 / 2� Area I I Employee ID# <br /> Grout Inspection By Date L4 1\1 7i y _: SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Z-L kOaa S CT -E-1 Q L,4_S <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash miffed Service Request# <br /> W POO 45 33 <br /> 9 /&D <br /> Z / <br /> CttDW3-061W O7:D:: /y /�/iT I^`��9� y/1� Page I o;: N:c�� r�n7rcr:nr. <br />