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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS 1 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS %'� !� Q-`�tl'.�•{' -/ !••) CITY/ZJP l•-1 ( •I ��i S a�-I�. <br />CROSS STREET �1L AP /'/,�t�• PARCEL SIZE LAND LAND USE APPLICATION# <br />OWNER NAME - G 1 I S PHONE J �/lJ' <br />OWNER ADDRESS i -1(f y Cf r h lr, ! k4 o7o <br />CITYISTATE/ZIP S r-J� (1 i �Sc�%� <br />CONTRACTOR _ �" 1 (� 1 t l 1 �� P 1 �' ( PHO '� U9 -l� :��) 7i] <br />CONTRACTOR ADDRESS IV' �( „(� j'. t 1 1 [tl CITYISTATFJZIP 9 l �Z <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSEYC-57 C-61 E D-09 1i Other NUMBER <br />CITY/STATEIZIP -r <br />ExpiRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibron ochlornomnanP rd3Q91 nrccnir rnZoz% <br />INTENDED USE ❑ DomesticJPrivate ❑ Irrigation/Agricultural :1 Industrial Water Quality Monitoring f: Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Tnr lalne•..i <br />• • • - -•-•�•••• •.��._ ncpdccincrn vveu vveo Alteratlontmoc1tication - Other <br />❑ Monitoring Well(s) # of wells E Soil Boring(s) # 01 bO""g3 Geotechnical <br />F. Out -Of -Service Well ❑ Out -Of -Service Well Renewal . Cmss-cnnnPPhnn Rdnnir <br />L <br />L Raise Well <br /># of borings <br />Drilling Method 1 Mud Rotary C Air Rotary i . Auger Cable Tool -1 Push Point 7 Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM SchedSteel L' Plastic C Stainless Steel 77 Other <br />Grout Seal Depth ft Neat Cement (94 lb bagl5-10 gal water)Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method i Pumped Free Fall ❑ Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By :� Driller E Pump Contractor C Other <br />= Concrete Pedestal CDlmensions: Width ft Length ft Thick <br />in Christy Box _ Stove Pipe PAYMEN <br />ulMP ubmersibleC Turbine C Other HP Pump Set ft Standing Water Leve <br />Plot Plan Re uirements: Attach a plot plan with the exact location of water well with respect to the followin <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, str%gVr�,.� <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. IF <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well:{F"rni uivn r ti <br />NI1NIN1t'1►1 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPE(.'TIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY q �` <br />Application Accepted By _ �+ Date cP l7d / C��i / �/j <br />Area Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date `/-2'L C_ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS &e �q3u) � <br />PE SC Received Check#/ <br />Codes Info B Cash <br />-By_ <br />Amount <br />Date Remitted <br />Permit/ <br />ervice R uest # Invoice # Well ID# <br />s ,c Y • 12w <br />jO 00 <br />i <br />page 102 WC11 `Puny P.rmn <br />