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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 /> JOB ADDRESS O I CrTY/LP <br /> m <br /> r D <br /> CROSS STREET I•1oY/W Vt r t/\' APN I p�{��`�f/�- PARCEL SIZE, % LAND USE APPLICATION#a p <br /> M1 N �-Qi V PHONE201 " 13 I 1 m <br /> OWNER NAME G ��`` }�� M <br /> OWNER ADDRESS %O NF-tip CrTYISTATE/ZIP ,Mti V I�J N /1 57-I (�Jf �'}, <br /> CONTRACTOR WOII I ( I N - PHONE_.}�/\OA 1�� 7,2, " I- 24 <br /> CONTRACTOR ADDRESS I CrTY/STATE/ZIP D11Oc1,QI�t� " Cf4Jql <br /> SUBCONTRACTOR '�_ PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> LICENSE C-57 C-61 :_ D-09 _ Other NUMBER"k=_ EXPIRATION DATE v/ <br /> DOMESTIC WELL SAMPUNG:pGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomeshUPrivate ImgalioNAgricultural Industrial _ Water Quality Monitoring G Soil Sampling/Charactenzabon PA <br /> Public Water System P&I ( EA►� <br /> If ciftefent Porn Owner. ',Vater System Name Contact Name or Phone Number �.Y/� <br /> TYPE OF WORK New Well Replacement Well ^Well AlterationrModificabon r Other V`6 <br /> Monitoring Well(s) #of wells O Sal Boring(s) #of boring' Geotechnical #of bon-XA!f 22 <br /> _ Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair SqN J <br /> New Pum _ Pum Replacement Pum Repair Raise Well Casm Oq Q <br /> WELL CONSTRUCTION ALTy p'Sf, OI NTy <br /> Drilling Method 1Mud Rota, Air Rotary Auget 'u Cable Tool Push Point Other <br /> Proposed Well Depth L1ltJ ft Excavation _in diameter - Open Bottom -_ Gravel Pack/Gravel Siz ' in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing D ameter in Thickness/Gauge!ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth In ft - Neat Cement(94 Ib bagr5-10 gat water) Sand Cement sack mix17 gal water <br /> 'f,Bentonitg(20%solids) _ Other <br /> Grout Placement Method 1pumped := Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller - Pump Contractor _� 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 /> MINI>IIAl 24 HOUR tri\"k\Cv\07'1CF RE.Q1 IRED FOR I\\PECTIONS-PI-EASE CALL(2o9t 953-7(,1)7 <br /> DEPARTMENT U E OI)ILY q <br /> Application Accepted By .� Date 3�1 2� Area I Employee ID# <br /> Grout Inspection By Date l« Z-L( SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info ash mlttedDate ^ Service Request# Invoice Well ID# <br /> �— ZO •.2 r <br /> 9 /&0 <br /> V.39 2 <br /> I <br /> Ftl[rR}.no Pt l•7 Vit_] �„ n"4- <br /> 1 9,31 3(> D <br /> 1 -7 SS,921-7+ <br />