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SAN.IOAtltlfttC�T Vy�RpN�IENT `EgLTi•IDEPARTMWELL/PUMP PERMIT <br /> 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT { CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> ,\1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS - ( L)p� (� P(4 4 v t��G ff CITY/ZIP �� C W' Vl� ��jS ,� mLn <br /> CROSS STREET ys in—V 1 T APN VC1 Uy 1 D <br /> PARCEL SIZE� LAND USE APPLICATION# p <br /> OWNER NAME m <br /> PHONE ���1 <br /> OWNER ADDRESS 3' F``� �/', f�GGt[�� ( C� �'t CITY/STATE/ZIP ' Vr �,f�� t�+'1 C6 �S r <br /> CONTRACTOR �1I` 11i l���t'l 1 t1 [`I PHONE �+�� <br /> CONTRACTOR ADDRESS 1� V at---X 'G(is CITY/STATE/ZIP 12-1 te- k-. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 'C-57 C-61 ❑ D-09 11 Other NUMBER-'----'� EXPIRATIONDATE <br /> DOMESTIC WELL SAMPLING: ,General Mineral/Coliform Bacteria(4391) vdibrornochloropropane (4392) Arsenic(4393) <br /> INTENDED USE X 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 4ew Well ,Replacement Well 1J Well Alteration/Modification CI Other <br /> Monitoring Well(s) #of wells (, Soil Boring(s) o or bo ings _ Geotechnical #of borings <br /> l l Out-Of-Service Well 17 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump 7. Pump Replacement IJ Pump Repair IJ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .1(Mud �o�ta , _! Air Rotary Auger I 1 Cable Tool 17 Push Point C. Other <br /> Proposed Well Depth ft Excavation r.7 in diameter Open Bottom A Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conduct Casing Depth ft <br /> Well Casing Diameter—�2— in Thickness/Gauge/ASTM SchedK 2-1 Steel X Plastic - Stainless Steel Other <br /> Grout Seal Depth S t ft _ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method i."-(umped '_ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By a Driller Pump Contractor Other <br /> Concrete Pedestal_Dimensions:Width ft Length ft Thick <br /> lin i.1 Christy Box Stove Pipe <br /> PUMP U Submersible LE Turbine :J Other HP 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 /> 3t9\I1tl wl?-i IIW R:1l91'.i C:h:Atl"IR 1:1l L'Ot WE'D I-(1R JN`,°i.f IIONS-I'LLASE t ALI.(209)953.769- <br /> DEPARTMENT U ES N L Y <br /> Application Accepted By Date /311 G �Z� Area Ll/�q Employee ID# <br /> Grout Inspection By Date'NH II = SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS PA <br /> PE SC Received Check#/ Amount Permit/Codes Info B sh Remitted Date Service Request# Invoic <br /> 7° i8 3 Zfo 6 �� <br /> qj,9 <br /> v--zq2ti M O <br /> qR q� <br /> GIl1x43-re;r»,0,;'!0222�-��� aI;<<: aUploaded into Acce l a W0I,h.,,,oPYm,t <br />