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1 WWCCLL/P n <br /> SqN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UMP r <br /> NON-REFUNDABLE PERMIT 1868 EAST HAZELTON Aq -L KTDN CA 95205 - (209)468-3420 <br /> CAL 2�9 )53-7697 FOR INSPECTIONS —_a <br /> JOB ADDRESS 1 1?y 4�^'�(� h� / EXPIRES I YEAR FROM DATE ISSUED <br /> CROSS STREET <br /> V r� + Cm/ZIP �J�' <br /> APN PARCEL SIZE LAND USE APPLICATION# <br /> �{l or o <br /> Cl <br /> OWNER NAME U Maw P. m <br /> PHONE N <br /> OWNER ADDRESS <br /> CfrY/SrArE/ZIp ( <br /> iCONTRACTOR I 1 I I V PHONE �'lV`1 fFZZ' I f'R <br /> +a) <br /> i (f�� t1 (VON 1 <br /> CONTRACTOR ADDRESS 1 CRYISTATEIZIPI`I U(K <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE7/ZIP LICENSE \�C-57 _ C-61 D-09 i I Other NUMBER 1 !�� EXPIRATION DATE V/��1 <br /> -m <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural - Industrial - Water Quality Monitoring i Soil Sampling/Characterization <br /> _ Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/ModiFicafion Other <br /> Monitoring Welljs) #of wells Soil Borings) a b nborings Ge.techn,.. aorbo ngs <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum Pum Re lacement u Pum Re air ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Rota Air Rotary Auger C Cable Tool Push Point Other <br /> Proposed Well Depth 0'ft Excavation lr in diameter Open Bottom `Gravel Pack/Gravel Size_in diameter <br /> Conduc1t�r Casing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameter W in Thickness/Gauge/ASTM Sched G Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1UT,_ft Neat Cement(94/b bag/5-10 gal water) Sand Cement 101 % sack mix/7 gal water <br /> BentoniteJ20%solids) -., Other <br /> Grout Placement Method Pumped E Free Fall - Other Retardant/Accelerator(name) <br /> �EDEsTAL�lnstalled By Driller PumpContractor OtherConcrete Pedestal Dimensions:Width ft Length ft Thck <br /> Christy Box 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 grater well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, eater 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 /> NUNINILTI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION'S-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By u Date 7­3 ze Area Employee ID# ST <br /> Grout Inspection By Dafe / X SPECIAL Well Permit <br /> Pump Inspection By Date X WAIVER Received <br /> Soil Boring Inspection y Date Constructed Well Depth ft <br /> COMMENTS Gf ✓ 60/ fI <br /> PE SC Received Check#I Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash C emitted Service Request# <br /> V d al1 zs AP2 mZ Im <br /> --►- <br /> p 5 <br /> ElID043-06 r�<<.1 w 2 Up o a e in o c c e a 'Pump I'cm;u <br />