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ED <br /> �__a L <br /> Uploaded into Accela 2�k24 CA <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEL.TON AVENUE-STOCKTON CA95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS �Q EXPIRES 1 YEAR FROM 1DATE ISSUED <br /> JOB ADDRESS Z l Wfll ''�; �/7 1 ��' CITYIZIP�\I�i(A"In <br /> CROSS STREET i1� ,h'/�I//,' APN �Y I vl�— I V PARCEL SIZE_ILAND USE <br /> //APPLICATION FF p <br /> OWNER NAME V✓, V 1 e 1 ' 1`� PHONE A 1-A 1� "/ N y <br /> ���� ^1 1��1 ,u�I �I Ir1rn/ N <br /> OWNER ADDRESS � � 1 V � V V I V RA CFTYISTATFIZIP j`1�1`� ��/7�/l�Yl W <br /> CONTRACTOR Iurl I N cj' PHO�NEE` ;/�/� I'1 ✓CONTRACTOR ADDRESS ' CITYISTATEIZIP C�sfio r Cd_I ll�*177 r);/7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CfTI'ISTATElZIP <br /> LICENSE C-57 C-fit D-09 U Other NUMBER Wt EXPIRATION DATE An <br /> DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ImgatienlAgricultural - Industrial Water Quality Monitoring = Soil Sampling/Characterization <br /> Public Water System <br /> If aitferenl rrom Owner. Wa:er System Name Conact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration;Modlfiration Other <br /> Monitoring Well(s) #of wells :. Soil Bonng(s) Yofbonngs _ Geotechnical 0ofborings <br /> Out-Of-Service Well - Out-Cif-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Cash <br /> WELL CONSTRUCTION <br /> Drilling Method . Mud Rot Air Rotary Auger - Cable Tool Push Point Other <br /> Proposed Well Depth MI ft Excavation 11 in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter I Conductor asing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched� _ Steel x Plastic Stainless Steel Other <br /> Grout Seal Depth�_ft Neat Cement(94 lb bagy,5-10 gal water) /I Sand Cement sack rnix17 gal water <br /> 1_3entoni a(20 io solids) C Other <br /> Grout Placement Method Pumped ❑ Free Fall Other Retardant i Accelerator(name) <br /> PEDESTAL Installed By - Driller D Pump Contractor Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin -: Christy Box 7 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, sewer or private disposal systems. Include distance from two property lines. For Domestic, <br /> A„riculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> :a HOUR ADVANCE NOTICE REQLIRED FOR INSPECTIONS-PLEASE CALL(209)953-7647 <br /> DEPARTMENT USE ONLY <br /> r I <br /> Applicabon Accepted By ll Date 1 Z 6 Z Area Employee ID# <br /> Grout Inspection By t 5_ Date 1 ;1-1011SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received PA y <br /> Soil Boring Inspection By Date Constructed Well Depth T <br /> COMMENTS <br /> PE SC �Received <br /> Checktf Amount Date Permitl Invoice 8 6 41V ell 1DIt <br /> Codes Info By Cash Remitted Service Re uest <br /> 0 029A A •�ki a sAPJ40 9 (v H RO °� <br /> a <br /> UIDMD-06 0{p1l+,p+_1 Page I nt_ <br /> w,u Puuq Pe <br />