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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 � AV CITY/ZIP �T( I-L ;J m <br /> �/ D <br /> CROSS STREET //`f7V APN l Q��?�O - 1 PARCEL SIZE l 74 LAND USE APPLICATION# V <br /> OWNER NAME /V/T�jLi ��C /PHHOONE(4N2 _ - P <br /> OWNER ADDRESS �//��//� CITY/STATE/ZIP La//// � lA 7S 1_ <br /> CONTRACTOR / � �`''�''/'' S /� uL/L �x�t' PHONE6F'!�O <br /> CONTRACTOR ADDRESS f�� �V ! vlL�✓/� �y CITY/STATE/ZIP <br /> SUBCONTRACTORGL�/l/Q PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 VC-61 ❑ D-09 ❑ Other NUMBER -!!w/j,�V t)e— EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)t- Arsenic(4393) <br /> INTENDED USE I)Lfomestic/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 ❑ New 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 ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> -Aoqew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,,VMud Rota ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point (I Other <br /> Proposed Well Depth�ft Excavation � in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 4:-L_Z1W ❑ Stee,!I,,,f,�oPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) and Cement /�'� sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodA)Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick r� <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Z Z Pump Set_ZdIV _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 /> \tl\INIUM 24 HOUR ADVANCE NO-1 ICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date q/%Zo ZS- Area Employee ID#_Jr <br /> Grout Inspection By _ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS X,,c, AjJ;� 7-el bt e--Sa74fOYtGY A,41't $.r�,rit <br /> i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> IQ,em <br /> B» yy8'� al�glZs �J 2 - II G <br /> DSt' � ' t' �7 •oo �t�la12S 25m �m <br /> �O 2 <br /> R <br /> p iy N <br /> EHD043-06 04/07R022 Page 1 of 2 A41`'Pump Permit <br />