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1 ` C WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 <br /> NON-REFUNDABLLEPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 34 cl 'D,-a_i S / ',Q� CITY/zIP 5 � , Gt SZI`--'c N <br /> r-1r <br /> CROSS STREET W LEIS APN <br /> PARCEL SIZE 6 LAND USE APPLICATION# <br /> OWNER NAME Allhe ( U J / <br /> PHONE ( c)4 ) 7� D O1ir <br /> OWNER ADDRESS k';4c� qVCU5 ��I/L0.• CITYISTATE21P ,� dt-iT", �A (pJ�S <br /> CONTRACTOR �� h11�ter y'GyiS ��(/ PHONE"92 V,C: 3 - S <br /> CONTRACTOR ADDRESS <br /> I�Q �AhfV►LV L� CITY/STATE2IP M,ctc(.Cn� ' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRA CTOR ADDRESS CITYISTATE21P <br /> LICENSE C-57 C-61 D-09 Other NUMBER I ISZ61C1 EXPIRATION DATE L 0 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE j\pomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System A. -"il <br /> if different from Owner Water System Name Contact Name or Phnoe t _ p <br /> 1 <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other C <br /> a.. <br /> MonitoringWells #of wells Soil Boring(s) u of hormgs , <br /> O ng(s) Geotechnical�- <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casin SAA, Zo�lS <br /> WELL CONSTRUCTION %JAQU <br /> Drilling Method �Mud Rotary Air Rotary Auger Cable Tool Push Point Other H EN�RONj9 Cp�H7'y A <br /> Proposed Well Depth s ft Excavation L2 ° in diameter Open Bottom X Gravel Pack/Gravel izFp, rdiameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Cam- in Thickness/Gauge/ASTM Sched '"ZI Steel Plastic Stainless Steel Other ft',- <br /> Grout Seal Depth {DO ft Neat Cement(94 ib ba9/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ABentonite(20%solids) XOther !f C rlt+c-, l•1 <br /> Grout Placement Method Pumped Free Fall Other ;e Retardant/Accelerator(name) <br /> PEDESTAL Installed By x Driller Pump Contractor Other <br /> )1 Concrete Pedestal Dimensions:Width�t _ft Length ft Thick L111 <br /> in Christy Box Stove Pipe <br /> PUMP X Submersible Turbine Other HP Pump Set l ZL' ft Standing Water Level I-2Q ft <br /> Plot Plan Requirements: Attach a plot plan %ith the exact location of water well iN ith respect to the following items: GPS <br /> Coordinates, proper-IN lines, adjoining properties, Hater bodies or courses, drainage pattern, roads, cxisting i�ells, structures, <br /> potential sources of contamination, sewers or private disposal sistems. Include distance from two property lines. For Domestic, <br /> Agriculture, Industrial well,provide location of anN water wells or surface water within 200' radius of proposed 11ell. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By f�/1 �1lr D to 'A'se26 Area Employee ID# :FT- <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> C�MENTS of <br /> 12am use- W A d L-*X"- hl - 23 Zto CDJ <br /> i PE SC Received Check#! Amount Permit/ r <br /> 1 Codes Info By_ Cash Remitted Date Service Request# Invoice# !111 # <br /> 'S ysr�gde Z6 5 <br /> 0 os? ?cry L 6 0 0 <br /> 1 uooa+of oao nor. � $� Y06I'V — Rw. ,,; <br /> Well Rwq>1'enup <br /> Uploaded into Accela <br />