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1 ` WELLIPUMP PERMIT <br /> VAN JoAou1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4684420 <br /> NON-REFUNDABLE PERMIT C i- 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> L ' y A LVI a <br /> JOB ADDRESS yjw Crn'RtP m <br /> �7/ G o <br /> CROSS STREET I < J r APN `9 f I PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE <br /> Ow%ER ADORESS CITY/STATE/7JP1Yhg / OtPI^V <br /> CONTRACTOR WWW6�}�yyV{'i II I �\`a- i N V' PHONE ],�'J�/'� <br /> CONTRACTOR ADDRESS IkAW" CITY/STATEZP �UUI J l�)� l� _���-7 <br /> SuBcoNrRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEMP� <br /> LICENSE Gb7 ❑ C-61 ❑ D-09 ❑ Other NulBER 0 — ExpmAroN DATE 4� <br /> DOMESTIC WELL SAYPLm:A General MineraWoliform Bacteria(4391)A Dibromochloroprepane(4392)L Arsenic(4393) <br /> INTENDED USE 1,10omestirJPrivate ❑ Ilrlgat10r1/Agri1 UltUlal ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampiing/Characlerization <br /> Public Water System <br /> H dMerwo ftm Owner. WaW System Name Contact Name or Phone Number <br /> TYPE OF WQW 0 NOW Well la Replacement Well 0 Wait AlterationlModification ❑ Other <br /> D Monitoring Well(s) #of wells ❑ Sod Boring(s) s a borings ❑ Geotechnical s of bmngs <br /> ❑Out-Of-Service WON ❑Out-OfService Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump 0 Pump ent 0 Pump R20ir 0 Raise Well Casing <br /> WELL CONSTR20M <br /> Drilling YatIMdtMud RoWy ❑ Air Rotary Elger Au a Tool 0 Push Point ❑ Other <br /> Proposed WeN ft Excavation In diameter i7 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conduct Casing in diameter / Cond Casing Depth It <br /> Weil Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seat ft ❑ Neat Cement(94 lb bag/540 gal water) Sand Cement sack mrx/7 gal water <br /> (20%Solids) ❑ Other <br /> Grout Placement Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Cor� ❑ Other <br /> ❑Concrew Pedestal❑Dirnenslons:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑Turbine D 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 /> I Vt.U I OR I'1Ml t I l(t"s-PL.t'iNL A. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L Date E Cy Area / Employee ID# <br /> Grout Inspection By Date 1 Q SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Solt Boring Inspection By Data Constructed Well Depth 1t <br /> COMMENTS <br /> PE SC Received ChecklH Amount Permit/ Invoice# Well ID# <br /> Codes Info By- Cash Remltted I I Datj Service R # <br /> �3ci� J <br /> I:HDW4 IOMrA21 Pace I or2 Wc11I F-4 P—d <br /> 1r T q 9Z <br />