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7 <br /> 1 WELLIPUMP PERMIT <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDA13L�jE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1?""'C Cn-YrlB In jAL4192 3 bDD <br /> CROSS STREET DOICIA0 N Z PARCEL SIZE LAND USE APPLICATION## p <br /> L Y PHONE <br /> OWNER NAME <br /> OWNER ADDRESS �i 1 D CIT//STATEIZP L IYI 7-1�l4a✓()7 <br /> CONTRACTOR I PHO <br /> NE <br /> ( ZZr�n 1�3G/�jr'J <br /> CONTRACTOR ADDRESS M 1 CITY/STATEIZIP <br /> SUBCONTRACTOR 0 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEFZJP <br /> LICENSE 32E ❑ C-61 ❑ D-09 ❑ Ottler NUMBER M1 22- E%PIRAnoN DATE <br /> DOMESTIC WELL SAMPuNG:-.General MineratlWiform Bacteria(4391)❑Dibnxnochiaropropane(4392);;Arsenic(4393) <br /> INTENDED USE rivate D Imgatlon/Agriwlturat ❑ Industrial ❑NK Water Quality Monitoring D Soil Sampfing/CharacteriratiorY�A <br /> ❑ Public water system �"'' N T <br /> If SiBerar firm Owner. Water System Name Corrals Name or Phone Number IN tz <br /> TYPE OF WORK -� El Replacement well D Well AlteraboN ther <br /> Modification ❑ OU Monitoring Well(s) #of wells [i Soil Boring(s) °of 6wngs ❑ Geotechnical #°r 20, <br /> j n <br /> ❑ Out-OfServioe Well fl Out-Of-Service Well Renewal ❑ CSC on Repair r+ <br /> D New PumpD PumpR D Pum Repair ❑ Raise Well CasingSq N�04 <br /> WELL CONSTRUCTION HEgLTI-1D pl'��NT �TY <br /> Drilling Method�� Air Rotary t7 Auger �I�,Cable Tod ❑ Push Point ❑ Other q RT NT <br /> Proposed Well %1 CAiiL1 —ft Excavation �_in diameter ❑ Open Bottom U Gravel PaddGravel SizeIt in diameter <br /> D Conduct Casing in diameter / Corxtuct ng Depth ft <br /> Well Casing Diarneb in Thickness/Gauge/ASTM Sched U Steel Plastic [7 Stainless Steel ❑ Other <br /> Grout Seal pe`}, It ❑ Neat Cement(94/b bag/5-10 gat water) n Sand Cement sack mixfl gal water <br /> 3errint� � (20%solids) ❑Other <br /> Grout Placemerd Method Tpumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> ��:�pDr�ler ❑Pedestal DDMnox ❑ Stove Pie <br /> IYP D Submersihlen Turbine D Obw HP Pump Set It 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 tine&, 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2")"3-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By V !. -- Date O % uZ Area f / Employee ID# <br /> Grout Inspection By �— Date Z Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Sal Boring Inspection By <br /> Date Constructed Well Depth ft <br /> COMMENTS �a( -(/-7}t � �YI l r3t 1 �' �Y t O AVIC <br /> Gvt�L u A J <br /> PE SC Received Checldf! Amount Date Permitt Invoice S Well IDIt <br /> Codes Info B Remitted Service Request# <br /> 43IF 190 b�— _� weo 439 I <br /> 3` <br /> EHVpK3 1%OW Pa�c I of 2 Well/Purim Permv <br />