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• ' E ILED <br /> l ` C WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE <br /> ^PERMIT <br /> S CALL 209 953-7697 FOR INSPECTIONS CEXPIRES 1 YEAR FROM DATE ISSUED <br /> SP <br /> JOB ADDRESS 13�}�1 lJ�(LIS CITYIZIP <br /> CROSS STREET l(! O LEIS I APN PARCEL SIZE 6 <br /> a.LAND USE APPLICATION III / p <br /> OWNER NAME �UI^((�, `,� jJ� ,}PHONE r o4 I ✓p7' D ur <br /> OWNER ADDRESS l24-I VS KLL CITYISTATEIZIP <br /> y' ��" (� 1•r <br /> CONTRACTOR �1t 4 WX/yI f r W��IS IVI(/ J� PHONE r S��f�(O1( 1 <br /> 3Z-7�O — <br /> CONTRACTOR ADDRESS ( , �l►YU ILIJ CITY/STATE/ZIP N"' (, /0(J V 71 <br /> XZY <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP v `� <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE L O <br /> DoMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Nomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization r� <br /> Public Water System ,- <br /> If different from Owner Water System Name Contact Name or Phone f p <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) u of hornnds Geotechnical <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection RepairQ " <br /> New Pump Pump Replacement Pump Repair Raise Well Casin SAAj ?026 <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Ef EN�RONMAP AP 11,C <br /> Proposed Well Depth 3US ft Excavation i2 „ in diameter Open Bottom k Gravel Pack/Gravel Slz rdiameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter ':;, in Thickness/Gauge/ASTM Sched '�M;j Steel Plastic Stainless Steel �Other <br /> Grout Seal Depth (DO ft Neat Cement(94 lb ba9/510 gal water) Sand Cement sack mix17 gal water <br /> ?(Bentonite(20%solids) X Other 'Y T r11 iU <br /> Grout Placement Method Pumped -*Free Fall X Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor Other <br /> )t Concrete Pedestal Dimensions:Width�/ _ft Length ft Thick L4.11 <br /> in Christy Box Stove Pipe <br /> PUMP X Submersible Turbine Other HP Pump ft Standing Water Level 1-70 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, proper N lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination, sei ers or priAate disposal s}stems. Include distance from two property lines. For Domestic, <br /> Agriculture, Industrial well,provide location of an- w ater i ells or surface water within 200' radius of proposed well. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �lr� Date Y!u?O�o Area T/�I? Employee ID# �_ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By to WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> C-O v1MENTS a i <br /> Om vise _Ab ___fU W IMW_ pIP ht - 2; k r Nevi <br /> PE SC Received Check#1 Amount Permit/ PID# r <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# We <br /> 70 ge ViS elWed Z6 5 <br /> ,a <br /> o c7,s�t ?•aIa l b D 0 <br /> f11D043.06040-Q022 �l nDb Pncr l�•�' Wcll,f',m;>Pornnt <br /> Uploaded into Accela <br />