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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSCTj (�(. I % PCZ L ,-v CITY/LP CROSS STREET Yfi: "I 'S J APN OWNER NAME OWN ER ADDRESS 11 %714 i J CONTRACTOR M i t � 'n r'D-,� " a r,,t U CONTRACTOR ADDRESS r� ") I i (►r 1 y`�„t,� i SUBCONTRACTOR t✓ SUBCONTRACTOR ADDRESS LICENSE ¢57 ❑ C-61 n D-09 0 Other NUMBER f CEL SIZE�1 LAND USE APPLICATION (# WCA PHONE / 3 2, CITY/STATE/LP -�/ PHONE - 7 / S_ CITY/STATE/ZIP + PHONE CITY/STATEIZIP ExPIRATION DOMESTIC WELL SAMPLING: L2 General Mineral/Coliform Bacteria (439 1) -_ Dibromochloropropane (4392) :: Arsenic (4393) INTENDED USE _Qmomestic/Private C Irrigation/Agricultural C Industrial 3 Water Quality Monitoring 0 Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well Replacement Well -- Well AlterationiModification G Other 7i Monitoring Well(s) # of wells ❑ Soil Boring(s) 0 of borings U Geotechnical # of bonngs Out -Of -Service Well ❑ Out -Of -Service Well Renewal 7 Cross -Connection Repair New Pump :: Pump Replacement ❑ Pump Repair 7 Raise Well Casino Drilling Method C Mud Rotary 0 Air Rotary C Auger F Cable Tool C Push Point C Other Proposed Well Depth It Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter 7. Conductor Casing in diameter i Conductor Casing Depth ft Well Casing Diameter _ in ThicknessiGauge/ASTM Sched �: Steel - Plastic 0 Stainless Steel C Other Grout Seal Depth ft ❑ Neat Cement (94 1b bagl5-10 gat water) ❑ Sand Cement sack mixl7 gal water ❑ Bentonite (20% solids) r Other Grout Placement Method ❑ Pumped C Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller D Pump Contractor L Other C Concrete Pedestal ❑Dimensions: Width ft Length ft Thick �in C Christy Box 71 Stove Pioe PUMP Submersible❑ Turbine 0 Other HP Pump Set_ I .`,,-.), ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUN4 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By Date �-� _ Area __ Employee ID# Grout Inspection By Date f I SPECIAL Well Permit Pump Inspection By Date G WAIVER Received Soil Boring Inspection By COMMENTS Date Constructed Well Depth 0 PE SC Received Check#/ Codes Info Cash Amount Permit/ PAYAAhN II Remitted Dato,I Service Request # Invoice # Ri i r, SAN OAQUIN CCU EHD043-0604007,:022 ,�C' i 1 0 li li trf^ 2 �' ( � G. L1 7' c) ` wd ;