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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 �U 10 1 1 i CITY/ZIP L1"G I (Yi lb3l 6 m <br /> �y D <br /> CROSS STREET l yy \} ^ y� AP Z-Z1I-1's0'5 PARCEL SIZE �'06 LAND USE APPLICATION# A <br /> OWNER NAME �+ l J�) G �)�LL�l�1lY i 7���CL PHONE ry- /�Z+�706V y <br /> OWNER ADDRESS r CITYISTATE/ZIPP—&�/ /J 'CA q- J�si'�C? <br /> CONTRACTOR / i/ J `) �P7HONEr ,hl^? /� _l✓r l�✓J <br /> CONTRACTOR ADDRESS <br /> d: �� CITYISTATE21P �,/G _��1/J/ ( !—�SUBCONTRACTOR I PHONE <br /> /^� )� c- � ' C j - 7 <br /> SUBCONTRACTOR ADDRESS C / "'l .!( CITYISTATE/ZIP�I�K.(.�UG�'iL1'ri, � ��J�-/ <br /> LICENSE C-57 C-61 D-09 Other NUMBER" ' ' ., EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ' Jew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well E Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump Pump Replacement G Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method . Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth I W-, ft Excavation I �- in diameter Open Bottom �v Gravel Pack/Gravel Size JF S i Je in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft/ / <br /> Well Casing Diameter�^ in Thickness/Gauge/ASTM Sched G V Steel ?Plastic Stainless Steel Other <br /> Grout Seal Depth I UIC' ft Neat Cement(94/b bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller *Pump Contractor Other <br /> Concrete Pedestal["'Dimensions:Width Lf ft Length !:7_ft Thick L <br /> in Christy Box Stove Pipe <br /> PUMP X Submersible.:; Turbine Other HP _2 Pump Set / C ft Standing Water Level 'Y'C .fi 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 /> �HSThH`M11 24 HOUR ADN'ANCr NOTICE REQ17IRED FOR INSPECTIONS-PLEASE CALL(209)1)5?-709" <br /> \\ /► DEPARTMENT USE ONLY <br /> Application Accepted By i�'J 4:5,4E1A, Date Z 6— Area Employee ID# /ls <br /> Grout Inspection By r �- �17 Date ��\k��kZ�Lt� SPECIAL Well Permit <br /> Pump Inspection By Date 1 Z F 7,4, WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# ell ID# <br /> Codes Info Cash Remitted Service Request# <br /> �Q� b Flo �l-IJ V-06 LA13125 AP25m1?(o5 <br /> 11 <br /> 36n. <br /> l Z•� y\3125 25co18(o� �o <br /> f9 O <br /> [Hn043-06 04/07/2072 Page 1 of �T Well Pump Pe <br /> Uploaded mm <br /> into Accela <br />