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i <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 ,.� I 1 +n l I� h CrrY/ZfP 1 ^A <br /> CROSS STREET yl� /�� �V� APN 2,2-0 �/~I -D PARCEL SIZE .! LAND USE nAPPLICATION# mA <br /> OWNER NAME 1 �'L�1 !.'1L-` � k oki v blym PHONE <br /> OWNER ADDRESS !/_� 7 P�_1 u ,1 �V, 0A . CITY/STATE/ZIP ► yl \of�)' `1 ' ' <br /> CONTRACTOR MASELLIS DRILLING, INC. PHONE 209-522-1928 <br /> CONTRACTOR ADDRESS 119 ALBERS RD. CITY/STATE/ZIP MODESTO,CA 95357 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 C-61 D-09 11 Other NUMBER 668622 EXPIRATION DATE 04/30l <br /> DOMESTIC WELL SAMPUNG:gGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) Pit <br /> INTENDED USE Domestic/Private Irrigation/Agricultural - Industrial Water Quality Monitoring a Soil Sampling/Characterization <br /> Public Water System Nr <br /> If different from Owner Water System Name Contact Name or Phone Number ^A <br /> TYPE OF WORK #Jew Well Replacement Well Ll Well Alteration/Modification Other `O <br /> I Monitoring Well(s) #of wells f I Soil Boring(s) u of boringsGeotechnical boring1/0 <br /> Out-Of-Service Well U Out-Of-Service Well Renewal Cross-Connection Repair H 1 Q�1* S <br /> New PumpPumpReplacement ❑ PumpRepair Raise Well Casing ��•r� O C <br /> WELL CONSTRUCTION <br /> (Drilling Method xMud Rota IL Air Rotary U Auger i Cable Tool U Push Point Ot r <br /> Proposed Well Depth__-'�ft Excavation _ in diameter fl Open Bottom Gravel Pack/Gravel Size in diameter <br /> ConductoL Casing in diameter / Conductor sing Depth ft <br /> Well Casing Diameter-U, In Thick ness/Gauge/ASTM Sched iMl Steel XPlastic rl Stainless Steel i- Other <br /> Grout Seal Depth tl It i Neat Cement(94/b bagi5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) L! Other <br /> Grout Placement Method Pumped It Free Fall U Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i I Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal UDimensions:Width it Length ft Thick <br /> �in Christy Box I Stove Pipe <br /> PUMP L:; Submersible[!Turbine . 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,pro%ide location of any water wells or surface water within 200' radius of proposed well. <br /> MINIMUM 24 HOUR ADS-ASCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9i3-7697 <br /> ,(jam DEPARTMENT USE ONLY �/ <br /> Application Accepted By Date '? /A/`Z®Lcf Area ! Q Q Employee ID# l <br /> Grout Inspection By 7 Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection Ejy. Date Constru ted Well Depth ft <br /> COMMENTS /Cz -e4I 7116) ,G�! <br /> PE SC Received Check#/ Amount Date Permit/ Involve# Well ID <br /> Codes Info B - h Remitted Service Re uest# _- <br /> go o •�u 2S ZSm t 118 <br /> t I Ilxu i-iN�}{.oT/Zp22 � - a.��loTs l zz��l orz l>,�u <br /> Uploaded into Ac c_e l a w�n,wmP <br />