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. E11�Iq� EI <br /> Uploaded into Accela <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFI.TON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES/1 jYEAGR� FROM DATE ISSUED <br /> - - I -- - 1 t 1 <br /> J08 ADDRESS � � � CITY/ZIP�I �� � � ��(P m <br /> tGI-ZlD- 11D l o <br /> CROSS STREET t /AEI �t� /)APN PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME ✓1 ej M1" `' ,_�^( 1PHHO,NE -A l��j <br /> OWNER ADDRESS (iZ�✓� N �1 NU ^!`1 1 CfTYISTATFJZIP 91_VON / -✓L�'}W��� ��'777 <br /> CONTRACTOR I vf)I 1 V V- ^ ( MWhP�HONn/E�l <br /> CONTRACTOR ADDRESS ' CITYISTATEIZIP 'y�I i t C I l ,�,r r 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATEIZIP f_ <br /> UCENSE C-57 -- C-61 D-09 Other NUMBERSku2-1-- EXPIRATION DATE Al' <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Imgation/Agricuftural -_ Industrial E Water Quality Monitoring = Soil Sampling/Characterization <br /> Public Water System <br /> If aifferent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Mod fication Other <br /> Monitoring Well(s) #of wells __ Soil Boring(s) #of borings Geotechnical Motborirga <br /> _ Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casio <br /> WELL CONSTRUCTION <br /> 'Drilling Method Mud Rot Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depthl ft Excavation 1 11 in diameter Open Bottom Gravel PackrGravel Size in diameter <br /> Conductor Casing in diameter f Conductor asing Depth ft <br /> Well Casing D amet� in Thickness/Gauge!ASTM Sched� _ Steel X Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ++``Sand Cement sack m4l`7 gal water <br /> I.Bentoni e 1201.o solids) ❑ Other <br /> Grout Placement MethodKPumped D Free Fail Other Reta•dant i Accelerator(name) <br /> �EDESTAL Installed 8y _ Driller - Pump Contractor ❑ Other <br /> Concrete Pedestal_.Dimensions:Width ft Length ft Thick <br /> in Christy Box - Stove Pipe <br /> PUU-P—_ Submersible Turbine Other HP Pump Set ft Standing Water Level - t <br /> Plot Plan Requirements: .attach a plot plan with the exact location of water well with respect to the following items: CPS <br /> Coordinates. property' lines, adjoining properties, water hodies or courses, drainage pattern. roads, existing wells, structures, <br /> potential sources orcontamination, wiser~ or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,Industrial well,provide location of an) water wells or surface water within 200' radius of proposed well. <br /> MININIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date S Z6 Z It- Area Employee ID# <br /> Grout Inspection By Date t7 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received Pqy <br /> Sal Boring Inspection By Date Constructed Well Depth T <br /> COMMENTS Q <br /> 1 <br /> PE SC Received Check#/ Amount <br /> Date Permit/ Invoice# N,/0 ell 011111 <br /> Codes Info By Cash Remitted Service Re uestX <br /> (� 0 a ���% a s 4<D q (D H Rp °U <br /> t 1.5 41P <br /> EIID01346 0407r: ' Page 1 of 2 W,11 P.,w Pr...,,. <br /> #�I a2�32z� <br />