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w � <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 ( 1 � t � (( 0O Avt 1 `,^ CITY/ZIP JIm <br /> m <br /> �j / D <br /> CROSS STREET �~tr ` r� �a AP r1 52 PARCEL SIZE r, % LAND USE APPLICATION# o <br /> z <br /> M <br /> OWNER NAMEL PHONE in <br /> OWNER ADDRESS �, �• (rhC T\C-\t > � CITY/STATE/ZIP <br /> CONTRACTOR �G r PHONE W!n^ 1n W�-011C-3 1 <br /> CONTRACTOR ADDRESS (j - I1 M6�tA4C'1 A b V CITY/STATE/ZIP umo ii., ` !/� —l!371, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI <br /> T <br /> �Y/STATE/ZIP <br /> LICENSE 13 (J <br /> 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 ❑ New Well ❑ Replacement Well I.-) Well Alteration/Modification 11 Other <br /> U Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ti New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C Other <br /> Grout Seal Depth ft U Neat Cement(94/b bag/,5-10 gal water) -1 Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 1-1 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall D Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ED Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal UDimensions:Width A� ft Length ft Thick 416 <br /> in D Christy Box ❑ Stove Pipe <br /> �PuMP [ii Submersible❑ Turbine ❑ Other HP iT' 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 /> NnNun %1 24 1IOL a L No I I( I R1.0t 1RED I-OR INsra:( 11001,-III t.stir.( 11 1209)0;3_7c1917 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date � Area / f r Empl-W <br /> Grout Inspection By Date ❑ SPECIAL Well P � <br /> Pump Inspection B ate-1 j,_S) LAA_(,. ElWAIVER Received RftEjVjF0 <br /> Soil Boring Inspection By ` Date Constructed Well Depth JULft <br /> COMMENTS <br /> ---- - - E /ROUENF-41 � OU TY <br /> TA i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# cM�19 <br /> Codes Info B Cash Remitted Service Request# <br /> -- -- <br /> 4+ B _ 4 4 0(0 3_(Q_-- -- <br /> fiHD1143.06 04/07Q012 �LA44ht' � 10-2 Well <br /> i 1'utn i Permit <br />