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r <br /> 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 /> JOB ADDRESS CITY/ZIP 011 <br /> C r� m <br /> CROSS STREET J . - APN ` PARCEL SIZE LAND USE APPLICATION# D 0M <br /> OWNER NAME I <br /> PHONE _ � � - � N <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR <br /> PH/ONEL^[�Y](TJ/ /� C <br /> CONTRACTOR ADDR SS �r�.L�-/� <br /> CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE �� /•�� F✓� <br /> SUBCONTRACTOR ADDRESS <br /> INT 44Z <br /> LICENSE WC-57 ❑ C-61 0 D-09 ❑ Other NUMBER <br /> EXPIRATION DATE _ <br /> DOMESTIC ELL SAMPLING: eneral Mineral/Coliform Bacteria(4391)16ibromochloropropane(4392)0 Arsenic(4393) <br /> >ENDED USE 'Domestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization p <br /> 0 Public Water System A <br /> If different from Owner. er System Name '1 <br /> Contact Name or Phone Number r <br /> TYPE OF WORK e e ' eplacement ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) # „s ❑ Soil Boring(s) #ofborings "Of <br /> ❑ Out-Of-Service Well ❑ Geotechnical----��" <br /> ❑ Out-Of-Service Well Renewal ❑ Crass-Connection Repair <br /> New Pump ❑ Pum Re lacement ❑ Pump Repair ❑ <br /> WELL CONSTRUCTION Raise Well CasingFiyV Q(/j^f <br /> Drilling Method)(Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other y�FpgRNTq� <br /> Proposed Well Depth—ft Excavation J44 —in diameter ❑ Open Bottom Gravel Pack/Gravel Size <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched-,2DD <br /> Grout Seal Depth 100 ft ❑ Neat Cement(94 lb bag/5-10 gal water Steel 0 Sand Cement Stainless Steel ❑ Other__ <br /> `�Bentonite(20%solids) ❑ Other sack mix/7 gal water <br /> Grout Placement Method 7X Pumped ❑ Free Fall ❑ Other <br /> ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> In <br /> )I(Concrete Pedestal❑Dimensions:Width _ft Length ft Thick <br /> ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other <br /> 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 ol-surface water within 200'radius of proposed well. <br /> 3II\T,WCf24 HOUR ADVANCE NOT!CE RFQC.tRF.r; -_ _ __. _ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By- / V Date l�1 1 Z 3 Area 0 �L Employee ID#_ S <br /> Grout Inspection By Date Z b 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By_ Date 141-11 ne.,f <br /> COMMENTS_ i`�'S E i�'' Cpnetructed h ft <br /> l owusy L Lv C(.,ytu�� i w 5¢rY U �..� a�u l is i 51,E <br /> PE SC Received hec Code Info Amount Date Permit/ <br /> Remitte Service Re uest# Invoice# Well ID# `+l <br /> V I✓ II is vuCOM 450'1-2. l� <br /> ERD043-06 IWN202I Page 1 Of2 <br /> Well!Pump Permit <br />