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EMAILED <br /> \ \ <br /> O <br /> V� <br /> 1 WELUPUMP PERMIT <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ✓ 1 V 1\ CITY/ZIP �M(jI 1 V 1 1 <br /> tn1 � _ D <br /> 10 <br /> CROSS STREET 1 V e AP N �~�30I PARCEL SIZE J4 LAND USE APPLICLA`TTION# (/{�J A <br /> OWNER NAME 1�I 1 l ' WONn)lq PHONE 1 f O f V y <br /> T( I � CISTATEIZIP CIT ?h2q y ;2 1 2 <br /> OWNER ADDRESS LVy-v -CONTRACTOR fI ' r ( ---- PHONE C52- - ) �_ <br /> -._ <br /> CONTRACTOR ADDRESS PfM CITY/STATE/ZIP J7o )rnG ' q �/% ] <br /> co <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> (LICENSE A C-57 C-61 D-09 Other NUMBER _ , i�-� EXPIRATION DATE V I /V•�� <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private iJ Irrigation/Agricultural Industrial Water Quality Monitoring Sol SamplinglCharactenzation <br /> Public Water System <br /> If different from Owner. water System Name Comact Name or Phone Number C� <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other vi <br /> CD <br /> Monitoring Well(s) #of wells Soil Boring(s) a of bonngs GeotechnicalNov <br /> Out-Of-Service Well Out-0 �/YYf-Service Well Renewal 7 Cross-Connection Repair 06 ?023 <br /> New Pump Pump Replacement P_u_Mp Repair iJ Raise Well Casing _ __S <br /> WELL CONSTRUCTION Qv <br /> Grilling Method�Mud Rota Air Rotary Auger Cable Tool Push Point L Other HEgLT/BONNE Oq NTy <br /> Proposed Well Depth mft Excavation in diameter Open Bottom .. Gravel Pack/Gravel Size in diarn /NEN . <br /> Conductor Casing in diameter 1 Conduct asing Depth ft <br /> Well Casing Diameter in Thickness!Gauge!ASTM Sched 2i Steel Plastic Stainless Steel Other <br /> Grout Seal Depth IOU ft Neat Cement(94 Ib bag/5-10 ga!water) Sand Cement sack mix/7 gal water <br /> Bentonite(2W;solids) Other <br /> Grout Placement Method Pumped - Free Fall 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 /> jPUMP Submersible. Turbine Other HP Pump Set ft Standing Water Level <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, semsers or private disposal systems- Include distance from h*o propert} lines. For Domestic, <br /> :agriculture. Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> E NOTICE REQUIRED FOR 1,NSPECT10lVS-PLEASE CALL 12091 X53 7697 <br /> A DEPARTMENT USE ONLY / <br /> Application Accepted ByDate k L l Area �t ( �l f� Employee ID# <br /> Grout Inspection By Date rl �PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date ] Constructed Well Depth R <br /> COMMENTS r 6�� j,v �Zy� C,��IZy' �Y Ula lt7 l Z ; Lt) r� z � l�av1; <br /> ww ��-( j�l�'l a louw�tk !-� �5 j? N 1._ t7 �t t�-c C a.J!• S f-v y'.. S a: L<. ,w <br /> PE SC Received Check#! Amount PermiU Invoice# Well ID# <br /> Codes Info By_ C sh Remitted Date Service R uest# <br /> EHD0/3-0601107.1022 Pa{x t of, 0.;i P:;nz Puma <br /> 170 2W I�3� <br />