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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96206 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 963-7697 FoR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />1 r CrrY/zlPAPN <br />y� PARCEL SIZE t,� LAND USE�APPUCATI/ONy,i#,7 �7 <br />111�r1 CI� 17— Or�:Z l9`lS� �1P T PHONE 2�(r9!-�`y'f��,�5 <br />CITY/STATE2113 <br />CONTRACTOR ADDRESS Y—C, <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 C-61 <br />DOMESTIC WELL <br />INTENDED USE <br />❑ D-09 ❑ Other <br />WI IMRFD <br />PHONE <br />CITY/$TATE/ZIP-C a <br />PHONE <br />CCIITY/STTATjEIZIIPP \ <br />05 G7 , 1 EXPIRATION DATE_ ✓o - <br />SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />Lor Domestic/Private ❑ IrrigationlAgricultural 11 Industrial u 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 ❑ New Well VReplacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Borin # of borings # of <br />9(s) ❑Geotechnical borings <br />a0 0Of-Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary U Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 Sched ❑ Steel ❑ Plastic ❑ Stainless Steel 11Other <br />Grout Seal Depth ft ❑ Neat Cement (941b bag/5-10 gal water ❑ Sand Cement sack mixt? gal water <br />D Bentonite (2D%solids) Cl Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other I a ryt e. (� [,�,�-� r- <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thlck <br />in ❑ Christy Box r7 Stove Pipe <br />—UMP 'V Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level �'Z 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 />�M- 'Iil1U ;? 241 .10UR ADV.-_riCE ii0T3CE RE Q ME D FOR ENSPE C f i0'i' - ?s -,EASE CALL (2 09) 953-769 <br />DEPARTMENT USE ONLY <br />/� L / <br />Application AccBptad By /f � /� / L C� C1 Employee IDO A <br />Grout Inspection B Date ❑ SPECIAL Well Pefmlt <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Baring Inspection By Date Constructed Well Depth f{ <br />COMMENTS _&0P.V-J ttil Ot-)3tJS „1,� LJ Ll5'�IvZ/ <br />PE SC Received Check#! Amount Permit/ <br />Codes 111f0 Gash Remitted Date ervi Request # Invoice # P Y I <br />OUNTY <br />HEALT <br />Page t ort <br />iueiiliRlIDp peflml <br />T <br />M <br />D <br />0 <br />m <br />m <br />CO3 <br />(A <br />