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1 WELUPUMP PERMIT <br /> SAN JOAQUIN CouNTY ENYmONMENTAL HEALTH DEPARTMENT 1668 EAST HAzELTON AVENUE-STOCKTON CA 95205 - (209)488-3420 <br /> NOWREFUND PERMIIT7 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JZ-0-70 Joe ADDRESS /V }�y�p V1 ///� �h CrrrR2r+ �y <br /> CROSS STREET \ V y"— VI I� _-_-APN 22' - N V nO PARCEL S�2�LAND USE <br /> APPLICATION# '( (��f� b <br /> OWNER NAME ��,� rDlh'lilu m 11 rl_&',P PHONE 11 jV�I I0/p�� L.�(J — 5o <br /> OWNER ADDRESS M 2)(Y, ,3 2 CIrY/STATEfZIP �a DI {4 V!C�Z22,0 <br /> CONTRACTOR na PHONE <br /> CONTRACTOR ADDRESS IN CD CITY/STATEMP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/7JP <br /> LICENSE C-57 ❑ G61 ❑ D-09 :j Other NUMBER ZZz EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:r General Mineral/Coliforrn Bacteria(4391) Dibromochloropropane(4392)!i Arsenic(4393) <br /> ktENDED USE estidPrivate ❑ IrrigetionlAgric ultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil SampfinglCharacterizationh <br /> ❑ Public Water System AA %,- <br /> N different from Owner: Wader system Nemo Contact Name or Phone Number - <br /> 11 M r <br /> TYPE OF WORK ,New well ).Replacement Well ❑Well AlterabonlModification ❑ Other <br /> ❑ Monitoring Well(s) #Of Weds ❑ Soil Boring(s) #0'6-bxJs ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ C nnection Repair 3 <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair D Raise Wei CasingSAN �O <br /> WELL NS tICTION F/F NVIR p IN CQ; <br /> N <br /> Drnlfv9 Method Mild Rota ❑ Air Rotary El Auger ❑ Cable Toot ❑ Push Point ❑ Other <br /> Proposed Well Depth_Nft Excavation 12,"in diameter ❑Open Bottom ❑ Gravel Pack/Gravel Size <br /> ❑ Casing in diameter / Conductorng Depth ft <br /> Well Casing Diameter_U in Thickness/GatgWASTM Schad ❑Steel tactic ❑ St ass Steel ❑ Other <br /> Grout Seat 7 it ❑Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mixf7 gal water <br /> Bentonite(20%Soils) ❑Other <br /> Grout Plw nw d Pumped ❑ Free Fall ❑ Other n Retardant/Accelerator(name) <br /> PEDESTAL lI stalied By ll Driller ❑Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width fl Length ft Thick <br /> lin ❑ Christy Box ❑ Stove Pipe <br /> I'm ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water weIl with respect to the foDowing items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or coarses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination,sewers or private disposal systems. Include distance from two property Bees.For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 2010'radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95.3-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B 41 Date 1/d 2- Area — Employee ID# <br /> Grout inspectioi By Date �� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date G WAIVER Received <br /> Sol Boring Inspection By /Date Con!structed Well Depth R <br /> COMMENTS C X1,5 10 wet -}T) be CIeS�/JV�I• eermtf- requilecj Tor- PUMP. <br /> w+r� <br /> PE SC Received CheckN Amount Date Pernw Invoice# WWI of <br /> Codes Info By, Cash Remitted I ServiceS <br /> 370 8 4q., . <br /> 3el 1 sS <br /> y3ya 476 <br /> EHDO/3-06 04g7I= L Page I oft Well I Pump Permu <br /> Cr <br />