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1 WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE- STOCITON CA 95205-(209)46B.1420 <br />NON-REFUNDARI F PFRUIT rA1 I 1enn. r.�.. <br />- — —� .�.... a wr wr curt marts NUNS EXPIRES 1 YF_AR FROM DATE ISSUED <br />Joe ADDRESS ti ClrvzP }t l t l 959 <br />CRO,SSSTREET (YJ1ia. u,= ' '1 - y <br />_ / ey APN 'T rr•!I tn) .ea "<�+!cI PARICELSUE ly'. LAND USE APPLx:ATION# AI� <br />OWNER NAME ��,4 CI �( I1 �P, l�f �l "�'✓L03/ <br />PHONE_ A/,� <br />OWNER ADDRESS �i�S • F1 �..,,V .. 4f' T CRYISTATE/ZIP_ <br />CONTRAGTDR _ ('_enS �I�Mj. PHONE /1161 fr52 <br />CONTRACTOR ADDRESS ),�_`_ ir,lcil ir'�1 1 "rfcw: CITYISTATEzP <br />SUBCONTRACTOR r' -,p PHONE _ /2os)-?69-7J(:kD <br />SIUCDNTRACTORADDRESS. JI'-, CITYISfATE/ZIPr T 'f'4 S5(;Z7 <br />Licexse O C-57 ❑i G61 0 D-09 ❑ Other NusmeR EXPIRATION DATE L7/A,/I o2y <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) G Dibromochloropropane (4392) _1 Arsenic (4393) <br />INTENDED USE O DOmesticlPrivate ❑ Irrigation/Agricullural ❑ Industrial ❑ Water Quality Monitoring IT Sag Sampling/Chamcter¢abon <br />❑ Public Water System <br />Ifdiaerentfiom Dwner. Water System Name CoMa4Name ar Phore Number <br />TYPEOFWOW 0New Well ❑ Replacement Well ❑ Well Aheration/Modification 0Other <br />0 Monitoring Wail(s) #of wells 0 Soil Boring(s) #0bOnrgs p Geotechnical y #or borings <br />❑ Out -Of -Service Well ❑ Out -O Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pum ❑ Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary ❑ Air Rotary p Auger ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth 17 ft Excavation C- Y in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sha in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depot ft <br />Well Casing Diameter in Thidmess/Gauge/ASTM Sched ❑ Steel 0 Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ` ft © Neat Cement (94 lb ba9/5-10 gal water) ❑ Sand Cement sack mbd7 gal water <br />0 Benton8e(20%solids) ❑ Other <br />Grout Placement Method ❑Pumped -0Free Fall OOther ,re...; i,l.' ❑ Retardant / Accelerator (name) <br />n <br />;RtNHP_ <br />riller C Pump Contractor 0 Other <br />tal❑Dimensions: Wiitlm_ft LengtftThick <br />Stove Pipeurbine 0 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 f0lloT41WWMQL G0 <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing well4t`i�QQ�s T E <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines"R M �e <br />Agriculture, Industrial iwell, provide location of any water wells or surface water within 200' radius of proposed we <br />1L <br />AILN'BlU.11,.2I HOUR AD\',L\CE NOTICE RFQLNRTD FOR INSPECTION'S -PL .:SE C.tLL t-'ogi 9534697 <br />DEPARTMENT USE ONLY <br />Application Accepted B' ,q <br />Y 1 Date �� L I �3r.,3 Area v � Employee ID# l� !* <br />Grout Inspection By Date ❑ PECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boding Inspection By Date Constructed Well,Depth ft <br />COMMENTS <br />PE Sc Recewed Check#I Amount Permit) <br />Codes Info I By --Cask _ Remitted Ua1e equest# 'y Invoice# --well10# <br />_ Service R <br />l <br />S - <br />rage r ora <br />(I0 <br />well IPe Perms <br />_N <br />g <br />9 <br />w <br />Iy <br />J <br />N <br />:NT <br />