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t <br /> EMAILED <br /> 1 A` \ 23 C�1� WELL/PUMP 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 /> (n <br /> /, <br /> JOB ADDRESS CfrY21P Vt rn <br /> D <br /> CROSS STREET Y APN � _ PARCEL SIZE _LAND USE APPLICATION# p <br /> M <br /> OWNER NAME fS <br /> (/. PHONE N <br /> /77 U7 <br /> OWNER ADDRESS CITY/STATE/ZIP Dy JI^,yr ��1�✓ <br /> CONTRACTOR t I)IN `^PHONEE/, lJ`Z�j �]' <br /> CONTRACTOR ADDRESS CITY/STATEIZIP �`�1O_�, X/S�J �-/"J 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP +^' <br /> iLICENSE 0-57 C-61 D-09 Other NUMBER EXPIRATION DATE Qq- <br /> DOMESTIC ELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestia'Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam pling/Characterizabon <br /> Public Water System <br /> If different fmm Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -placement Well L'. Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Lj Soil Boring(s) r•of bonri Geotechnical a of bOf7ngs <br /> L Out-Of-Service Well Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> New Pump D Pump Replacement Pump Repair 0 Raise Weil Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud otan Air Rotary Auger Cable Tool Push Point 0 Other <br /> Proposed Well Depth 06 ft Excavation it in diameter Open Bottom )(Gravel Pack/Gravel Siz in diameter <br /> ._ Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter'la in ThicknessiGauge.!ASTM Sched x Steel Plastic Stainless Steel Other <br /> Grout Seal Depth f ft G Neat Cement(94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> �(Bentonit (20%solids) 0 Other <br /> Grout Placement Method - Pumped 0 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller r' Pump Contractor U Other <br /> C Concrete Pedestal Dimensions Width ft Length ft Thick CID <br /> lin C Christy BoxStove Pipe <br /> _ t <br /> PUMP 0 Submersible Turbine Other HP Pump Set ft Standing VFepttr�" IRiM� ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the M'1 owing 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 proper•t" lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed m ell. <br /> HI\INIt%1 24 tl(WR ADVANCt' Not'11(4' REQ1110:14Felt( t\SPI eI"ft t\,,-P1 F%S! L(2191 h;- <br /> DEPARTMENT US N L Y c/�+ <br /> Application Accepted B Date (Y Area i 9 Employee ID# <br /> Grout Inspection By - — Date <br /> SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring spection By Date Constructed Well Depth ft <br /> COMMENT <br /> PE SC Received Check#/ Amount PermW <br /> Codes Info By Cash RWnitted I Dat Service R st# Invoice# Well ID# <br /> EnD0i3-06 WN7 ✓ V/) 1 ` 1 n /` r)�v <br /> rWell-Pump PC=[Z <br />