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i <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENvwoNMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE I SUED <br /> w <br /> JOB AoOREssTru NO CTTY21P m <br /> CROSS STREET APN�"-2-2 01 CEL SIZE LAND USE APPLICATION# <br /> PHO!¢YJ r4. I�JIJ , m <br /> OWNER NAME /1y � <br /> OWNER PTA CFTY/STATEMP -01�)K � C J�(� <br /> � <br /> CONTRACTOR1F 1 PHONE g <br /> CONTRACTOR ADDRESS CITYJSTATEIZJP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C57 ❑ C-61 ❑ D-09 ❑ Other NUMBER � Exa1RATION DATE <br /> 145J��_�:.J <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)❑ Dibromochloroprepane(4392)C Arsenic(4393) <br /> INTEye USE I� ❑ IrrigationiAgricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil SamplinglCharacter9za6o A Y� <br /> ❑Public Water System — r <br /> it different frau C%Tmr: Weller Systern Name Contact Name of Phone Number <br /> TYPE OF WORK New Well 'A:Replacefnent Well ❑ Wel AlteretiodModifi Urn ❑ Other <br /> D Monitoring Wel(s) #of weft ❑ Sod Boring(s) #4 borings ❑ Geotechnical� #or s , ?O� <br /> ❑O � Well ❑ Out-of-Service Well Renewal ❑ Cross-Connection Repair v^+ V <br /> pp{-� JOq <br /> ❑ New ❑ ❑ Pum Repair El Raise Well CasingyEENV1R QU//y co, <br /> WELL g9"r Rt 0QN RTME <br /> Ell Tq T Y <br /> Drilling Method Mud Rotary ❑ Air Rotary ElAuger ❑ Cable Tool 0 Push Point ❑ Other <br /> � <br /> Proposed Wad ��ft Excavation _ in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size LV in diameter <br /> D in diameter / Conductor sing Depth ft <br /> Other— <br /> Weill Casing Di��7ft <br /> hidcneWGaugeIASTM Sched _ ❑ Steel Plastic ❑ Stainless Sleet ❑ Other <br /> Grout Sal ❑ Neat Cement(941b baW5-10 gal water) ❑ Sand Cement_ sack mixl7 gal water <br /> (2D%solids) ❑Otl►er <br /> Grout Placement Pumped ❑ Free Fan ❑ Other ❑ Retardant/Accelerator(name) <br /> rin'n—__ <br /> EMTAL Installed By InDriller ❑ Pomp CorWaC Dr ❑ Other <br /> ❑ Concrb Pedestal❑DbFensions:Wkdth ft Length ft Thick <br /> ❑Christy Box ❑ Stove Pipe <br /> ft-MP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Starxi ng Water Level 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 weds, 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 /> �II♦I�It U 'a 1101 K \iQi ti{h i!10R i\`,i':( :tkIN - I't KA`.E!. ILLI.(1114) <br /> DEPARTMENT US ONLY p <br /> Application Accepted By <br /> Date Z7i Area � /� Employee ID# <br /> Grout krLspecUon By y J:jf:Va:C Ile, Date `f [I SPECIAL Well Permit <br /> Pomp Inapecbon By Date ❑ WAIVER Received <br /> sod Boring lropt By Date Constructed Well Depth tt <br /> COMMENTS P r i <br /> PESC Received CheckX Annaunt Dsns Pernrtl Invoice# Weil las <br /> Servira Request v <br /> Codes Indo By Cash ltted <br /> L17-7Zp Zz IBJ <br /> IV 76 - <br /> EHDM3-06 HQ25=1 <br /> F.S.I ore Wru I w,w P—W <br />