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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 /> t - <br /> JOB ADDRESS O CITY/ZIP <br /> C • pvf'd I� 7Q D <br /> CROSS STREET <br /> ( �-}h-Lwc� APN 1 1 (��T� PARCEL SIZE fJ LAND USE APPLICATION# <br /> OWNER NAME A . 11 '1 PHONE_ `' ) �l f 7 I (�L� y <br /> OWNER ADDRESS 11" 1 CITY/STATE/ZIP u J I <br /> CONTRACTOR �/ '� PHONE �0 U CIU , 01 <br /> CONTRACTOR ADDRESS U , J1`Y/"� 1 '�C�`�I too CITY/STATE/ZIP �,%J V 6/L <br /> SUBCONTRACTOR �' \` (/� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ( r <br /> LICENSE C-57 ❑ C-61 ElD-09 ❑ Other NUMBER 04--I k1f& EXPIRATION DATE "/�` <br /> DOMESTIC WELL SAMPLING:19 General Mineral/Coliform Bacteria (4391)XDibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural Industrial ❑ 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 11 Other <br /> 11 Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings Geotechnical #of borings <br /> 1 Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> Ei New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Ski Mud Rotary Air Rotary Auger Li Cable Tool Li Push Point ❑ Other <br /> Proposed Well Depth 2-c; ft Excavation in diameter Open Bottom X Gravel Pack/Gravel Size in diameter <br /> 11 Condu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Scheme L.l Steel A Plastic I Stainless Steel Other <br /> Grout Seal Depth_O—A-,n_ft ❑ Neat Cement(94 lb bag/5-10 gal water) [.1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) LI Other <br /> Grout Placement Method' Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> I.1 Concrete Pedestal ["Dimensions:Width ft Length ft Thick <br /> in 1] Christy Box C, Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level 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 /> MINI;MUNI 24 1101'It ADVAN(E'V'0'L'I(:E:Rl"'Ot IRED FOR IN SPEC-1 IONS-PLEASE('ALL(209)953-7697 <br /> J DEPARTMENT US�E O LY <br /> Application Accepted By Date 12 9 7� Area <br /> QMT <br /> Grout Inspection By Date ( z- 1 SPECIAL W�ff � C <br /> Pump Inspection By Date ❑ WAIVER Received D <br /> Soil Boring Ins ection By Date Constructed Well Depth�IC 19 ft <br /> COMMENTS Ic f �L /"� cc' c i ./uc_� sve.s( _jZ% 'c: t C>� <br /> l P t <br /> T <br /> C. <br /> ct ,&V 3z,xo,, C A.- DEN7W 1 <br /> PE SC Received heck Amount Permit/ <br /> Date Invoice# -mIIID# T <br /> Codes Info By ash Remitted Service Request# <br /> Y3 m 6 1 0 220 20 q 3WIP004514k <br /> I U 220q1s5' <br /> �35 76 <br /> EHD043-06 04/07/201-2 � _ i ��yl Page 1 of 2 Well/Pump Permit <br />