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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 9$3-7697 FOR INSPECTIONS ( EXPIRES <br /> �'I^YEAR FROM DATE ISSUED <br /> �J� <br /> JOB ADDRESS � <br /> _ CITYIZIP MCIMN}�111 V 1 L V m <br /> CROSSSTREET ��l�+\ APN- I l � � v�V PARCELSIZE ✓ '� LANG USE <br /> 1A'/�IPPLICATION# A <br /> OWNER NAME I f Il Cff f 1 }pI v" PHONE �jl 2 -31 I N <br /> !OWNER ADDRESS1�I I UV \I' IVI 1/I( j V C� CITY/STATFJZIP •� jl/�' ljT1 V ��"J�� 1 <br /> CONTRACTOR nPHO/N�'JE(//�. (/^ 7 <br /> CONTRACTOR ADDRESS CRY/STATE/ZIP 1�LLCJr ' l� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP �7'l <br /> LICENSE C-57 C$1 D-09 Other NUMBER T2L EXPIRATION DATE ,JV <br /> DOMESTIC WELL SAMPLING:jt•General Mineral/Coliform Bacteria(4391)x'Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domest c1Private ;' Irrigation/Agricultural Industrial D Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well :- Replacement Well - Well Alteration/Modification C Other <br /> _ Monitoring Well(s) #of wells D Soil Boring(s) is of borings Geotechnical k of borings <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pum Pump Replacement D Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method xMud R tory Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation �_in diameter ^ Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conduc n diameter / Conduct asing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It D Neat Cement(94 Ib bag15-10 gal water) X Sand Cement '� sack mix/7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method*Pumped 7 Free Fall I_! Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _: Driller '� Pump Contractor D Other <br /> Concrete Pedestal -Dimensions:Width ft Length ft Thick <br /> �in Christy Box � Stove Pipe <br /> PUMP L Submersible__ Turbine Other HP Pump Set It Standing Water Level It <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the folloviing 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 /> NIININIUM 24[it t-R AtA A\CE\U"Il(t:RF(Jl IRF])FUR INSPFC[7U\S-PLEASE CALL(209)953-7697 <br /> DEPARTMENTI{U E ONLY 2 <br /> Application Accepted By � Date <br /> ` a Area i �i Employee ID# S <br /> Grout Inspection By Date J SPECIAL Well Permit <br /> Pump Inspection By Date 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> CO ENTS 90/14c4" C',/ittr <br /> PE SC Received Check#/ Amount Date Permit! Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 4 39 13 <br /> 43`(2 '' S <br /> EHU0421•06 03:V7:U2: Pag <br /> �J"-/ e I of: 'A"11 Punroe�m <br /> Pu <br />