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EMAIL <br /> WELL/PUMP PERMIT <br /> SAN Jana �NVI NMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT `` 1 CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM�}DATE ISSUED <br /> JOB ADDRESS ., I �A CITYIZiP L <br /> I IZ 7? L S i C G'7.� <br /> CROSS STREET APN PARCEL SIZE ( �3 LAND USEAPPLICATION# / p <br /> /l <br /> OWNER NAME `'�t c,� : LL PHONE) C�4.5 15 5 6—c f Ici c W <br /> OWNER ADDRESS P.C' I'D( x '.�6�j CITYISTATEMP LQ(t I CA 9 5 ;t4 <br /> CONTRACTOR �' f 7 `` I�( t I 1 r) `I PHONE <br /> CONTRACTOR ADDRESS L CI' ' I7 ,� 4 2 CITYISTATEIZIP G <br /> ,SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Z /� <br /> LICENSE 'XC-57 C-61 D-09 :I Other NUMBER 3-� ) 7 EXPIRATION DATE / <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) DIbromochioropropane(4392) Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Irrigation/Agricultural X Industrial Water Quality Monitoring Soil Sampling/Characterization q Y <br /> 0 Public Water System_ 10NT <br /> If different from Owner. Water System Name Contact Name or Prone Number <br /> TYPE OF WORK New Weil Replacement Well 0 Well AlterationlModification Other `D <br /> G Monitoring Well(s) #of wells D Soil Boring(s) #of bon ngs Geotechnical #of be R <br /> 0 Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair S.4 IV ?4 <br /> New Pum Pum Replacement um Raise Well Casing6A/J,/O,—q Q <br /> WELL CONSTRUCTION ly 1 LTN� NII�FN LINTY <br /> Drilling Method Mud Rotary Air Rotary ; AuX-� b ool Push Point OtherF�'gProposed Well Depth�7)_ft Excavationto diameter Open Bottom /,Gravel Pack/Gravel Size !Conductor Casing in diamnductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C �- Steel Plastic Stainless Steel Other <br /> Grout Seal Depth I C( ft Neat Cement(94 lb bag/5-10 gal water) p;Sand Cement I C 3 _sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method A Pumped Free Fall Other Retardant l Accelerator(name) <br /> PEDESTAL Installed By ';4 Driller Pump Contractor Other <br /> Concrete Pedestal .Dimensions:Width_ ft Length ft Thick <br /> lin Christy Box Stove Pipe <br /> PUMP Submersible:: Turbine -' Other HP 7 t/.� Pump Set_L2)' ) ft Standing Water Level 5�.' 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 /> N1l\il1LNI 23 1101 R AIM ANt 1.NO I(L RLQUiRL1)1(1R 1\1,11t( 110\,S-P11-ASL(:Ai.l-(209)9i3-7(,97 <br /> DEPARTMENT rZ <br /> pNLYApplication Accepted By Date 7/ z7 Area_ � /I Employee ID# �� <br /> Grout Inspection By� 9j1 Date_ '�'ZY SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received _ <br /> Soil Boring In pection By Dae Y Constructed Well Depth Z65 ft <br /> /k <br /> COMMENTS • 16i.�@�� -. ms' i 10 ICS-S' � iwl Z Er-e ce fie-i- pee- T-4.#^. <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Request# <br /> s i •zo +24 m <br /> 3g� b Z 3- -74 P <br /> ElID043-06 04M7,7022 17 9 66 3 3 7 Paxe""2 <br /> Neil'N'm Penna <br />