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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVVIV-Mht-UNLIAt3LL YtK4MI I <br />ALL (LU11)1150.5/-f 11/ FOR INSPECTIONS <br />tXI'IK1= P I YEAR FROM DATE ISSUED <br />JOB ADDRESS V 3 / <br />, / - /A -t <br />.,V % 4-eik loo e �e / CITY/ZIP —7fiiG (GMK/ r� <br />L,q <br />CROSS STREET r,V,1 <br />A', 10el AP Qq- 07 Q �L PARCEL SIZE S/ <br />LAND USE APPLICATION # <br />OWNER NAME <br />-00/1 co <br />PHONE 209 110/' <br />78 <br />91 <br />OWNER ADDRESS /77(a <br />� /�/'de <br />t 2d CITYISTATEIZIP <br />L/n4il� c/t <br />g5 Z <br />;3� <br />J <br />CONTRACTOR K m <br />2,( t� IytG (17(1, <br />PHONE 2� % <br />% - - Z7S 7 <br />CONTRACTOR ADDRESS P0 <br />1 <br />604 3 Z9 CITY/STATE/ZIPVA <br />A` 1,( 50srnxs <br />T <br />41(g525r'L <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 -i C-61 C D-09 - Other NUMBER Ael M I/ EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE �KDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial C Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: `Nater System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Y New PumD ❑ Pumo Reolacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling MethodMud Rotary Air Rotary = Auger Cable Tool C Push Point Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />F Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel E Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack m&7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall -- Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor = Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP__J_ Pump Set Z( (o ft Standing Water Level _2L-5� 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) ithin 200' radius of proposed well. <br />MINEN11 11 24 HOUR .XD\ ,INCE \OTICI: RI:OLIRI:I) FOR INSPI (l IONS- PLEASE CALL (209)Q53-7697 <br />�j DEPARTMENT USE ONLY LJ <br />Application Accepted By r—/�— lJ �� Date 3 x �� Area I C C Employee ID# <br />Grout Inspection By Date C SPECIAL Well Permit <br />Pump Inspection By I Date �-7 __ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS —J Jew Weil W CQc�a &r 3 <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ Invoice PA MEfNT ID# <br />Info 151 Cash Remitted Service Request # <br />-RECEIVED <br />— <br />C. <br />SAN -1 UIN COUNTY <br />ENVIR NMENTAL <br />HEALTH PEPARTMENT <br />E1ID043-06 1 011 51202 1 Page I of 2 Well! Pump Permit <br />