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- FEMAILED <br /> 1 ►1. M WELLJPUMP PERMIT <br /> SAN JOAOUI �i A4ili DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 85205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL" 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS I y� - CITY17JP�I �( C J l r�{ <br /> CROBB STREET rV L APN Zo9^�S�-O� PARCEL.SIZE /'$r LAND I}BE APPLICATION# <br /> OWNER NAME ft..Cl /' �/ PHONE�! /J}� /^y �y _ 7 <br /> OWNER ADDRESS 1 3 /+CEJ Q CIrY)STATEall Ira e-!-t e A qI�—3! I <br /> CONTRACTOR ,^JY' S h J PHONE (�� G zozel) <br /> CONTRACTOR ADDRESS CITYISTATECLP 1f19S'J't L�]T3 V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI YISTATE/ZJP <br /> LICENSE t C-57 VC J D-09 C. Oihet NUMBER E%PIRATION DATE. 32 Z ZZ0�� <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) DibromOChloropropane(4392) Arsenic(4393) <br /> =LMM�LIIVO Domesic?Private la IrrigationlAgricultural industrial ;Water Quality Monitoring 5 Soil SamplinglCharacterization <br /> Public Water System <br /> U dlflerenl from Owner: Waler Syslom Nama Contw:t Name of Mcne Number <br /> TYPE Of WORK -i Now Well Replacement Watt CI Weil AlterationfModifieation Other <br /> Monitoring Well(s) #at yells t7 5031 Boring{s} °`b°"'0 Geotechnical Ae bor ngF <br /> Out-ofService We C Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pum Lum Replacement Q Pump Re air i! Raise Well Casing A N <br /> WELL CONSTRUCTION <br /> Drilling Method _i Mud ROt AIr Rotary 1 Auger :3 Cable Tool Push Point other �E1 D <br /> Proposed Well Depth It Excavation in diameter i Open Bottom 3 Gravel Pack/Gravel Size v ��iq�ii oter ' <br /> Conductar Casing i n diameter f Carlductor Casing Depth ft �Y 6 �c <br /> Well Casing Diameter_in ThlcknerssrGauge;ASTM Schad ! Steel i Plastic -Stainless Steel of o U <br /> Grout Seal Depth ft ll Neat Cement(94 lb bag/5-10 gal water) ri Sand Cement S N <br /> Bentonite(20%solids) I'- Other LN 7Y <br /> Grout Placement Method '-i Pumped C Free Fall I other Retardant/Accelerator(name) <br /> PEDESTAL Installed By _, Driller t Rump Contractor Other - <br /> t Concrete Pedestal_:Zimensions:Width It Length ft Thick <br /> lin Christy Box C Stove Pipe <br /> PUMP Submersibles_:Turbine D other HP Pump set it 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: GFS <br /> Coordinates, property lines, adjoining properties, water hodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination,sewers or private disposal systems. Include distance from two property lines. Icor Domestic, <br /> Agriculture,industrial well,provide location of any water ivells or surface water within 200'radius of proposed well. <br /> MINI>IUM 4.1 IIO1,;R,%IfN AN(L Ntt'1'I(:E:.REOt IRrl)I OR -PLEASE c-vLL 1209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 1 L3 ZOZ1p Area Employee ID#f 67- <br /> Grout <br /> TGrout Inspection By Data - PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ift ped 'n By Date Cons cted Well Depth ft <br /> COMr�eNTs `I Z (A - 1 r <br /> Ud"( ownerr. <br /> PE SC Received Che,-k#! Amount Permitf <br /> Codes Into B Cas Remitted <br /> Date Service -seat#t Invoice# Well ID## <br /> o <br /> GIItNf45-i1504W1022 - /U.c/ � PK�142 1vcuIpavA-rit <br /> 13�ri C I21 <br /> Uploaded into Accela <br />