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El1�lAIL„Ep <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZ-ELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> i----- 1"I! 'V �IV V.. - .._ CITV/Z!P � V'V "I���U m <br /> (JOB ADDRESS <br /> iNG112f,I�S S "��' I�tl- �i�D <br /> (CROSS STREETNW] <br /> APN _ / _PARCEL SIZE LAND USE AP�IJP(LI�nCALTIO�NrZ_ p <br /> OWNER NAMI �1 V\- Gil - PHONE V 1 tJ I✓ - (��ly V? <br /> OWNER ADDRESS 10 0 �' ------ — CITY/STATE/ZIP n�ant�cw <br /> CONTRACTOR A• OK VWINO <br /> ' `V _ PHONE [�)-7—� 1,174—� <br /> CONTRACTOR ADDRESS 1L� fl� J .., CITY/STATEJZIPsj-o 0 19-1/ <br /> (SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-:i' C�i1 D-OP ' Other NUMBER t 0Q12 - EXPIRATION DATE '* 2 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private IrrigationlAgricultural _. Industrial U Water duality Monitoring ❑Sal Sampling/Characterization <br /> Public Water System <br /> If diferent from Owner Waver System Name ConWA Name or Phone Numoer <br /> TYPE O°WORK N9w Well _ Replacement Well ❑Well Alteration/Modification 0 Other <br /> Monitoring Well(s) #of wells D Soil Boring(s) °°f b0nr'� Geotechnical p°f borings <br /> 7 Out-Of-Service Well <br /> Out-Of-Service Well Renewal U Cross Connection Repair <br /> _ New Pump Pump Replacement I Pump Repair Li Raise Well Casing <br /> I WELL CONSTRUCTION <br /> Drilling Method�Mud R 1 Air Rotary Auge Cable Tool a Push Point C Other <br /> I l 1 <br /> Proposed Well Depth_���R Excavation �_in diameter U Open Bottom � Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / ConductorCasing Depth ft <br /> Well Casing Dia r in Thickness/Gauge/ASTM Sched�— U Steel Plastic U Stainless Steel Other <br /> 17 Grouts Seal Deou% r R C Neat Cement(94 lb ba(y5-f0 gal water) Sand Cement sack mix/7 gal water <br /> �--�/ xBent ite 096 solids) Other <br /> IGrout Placement Methtfd .] Pumped Fres Fall Other Retardant!Accelerator(name) <br /> (PEDESTAL Installed By Driller Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width ft Length ItThick <br /> in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set R Standing Water Level fl <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, adjoinim, properties, %cater bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of conlaminatiun. tic%tort or pricale disposal systems. Include distance from two proper-11% lines. For Domestic, <br /> Agriculture,Industrial well.protide location of any water wells or surface water within 200' radius of proposed well. <br /> MINI IA1 24 11tH R TIT% t\r'I %til It t 11101 lltt111 Olt I\Nht(-Ter)\%"PI F 1tiF.t.'ALI,(-'MJ)041-7(0- <br /> .DEPARTMENT <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By i Date rri Area `� Employee 04 <br /> Grout Inspection By Date _ I I Ti`i SPECIAL Well Perris, <br /> Pump Inspection By Date WAIVER Received �.J <br /> I ° j � <br /> Soil Boring Inspection By Date Constructed Well Depth � ���A <br /> � wCOMMENTS � <br /> I VPN <br /> MAR <br /> LL!� C,CJS Cie 6-C_^-r— — <br /> — — Q — <br /> PE SC Received Check#/ Amount Permit/ <br /> Date Invoice JV � Well <br /> Codes Info By Cash Remitted " Service Reque <br /> ice st# _ <br /> - -4-5300 <br /> EH1xMltb U%97.-0L p'%'1 0 --- W.11:Pump Pcrrnd <br />