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1 ��•� 2� ..- WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I EAST HAzELToN AvENUE-STOCKTON CA 95205 -(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> � N <br /> JOB ADDRESS 7 C.MP /j <br /> my <br /> CROSS STREET /� APN \f'v�U PARCEL SIZE LAND USE APPLIICAAnTFION(#�}�(�(�(�J A <br /> OWNER NAME 1 V V 1 PHONE 0 f 7VSJ_�L m <br /> O! <br /> OWNER ADDRESS 1-1 <br /> �/1 r' CITY1STATE/ZIP 1 i J C110 q 5 J� <br /> CONTRACTOR MKIE I l N N V- A/►PHONE <br /> C 2-.1 1ry—_0 <br /> CONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEIZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 0 Other NUMBERMItIm— ExPmmm DATE <br /> DoMEsnc WELL SAMPLING:❑General MinerallColiform Bacteria(4391) Dibromochbropropane(4392)U Arsenic(4393) <br /> INTENDED USE DomesticlPrivate 0 Irrigation/Agricultural ❑ Industrial CI Water Quality Monitoring ❑ Sal Sampling/Characterization <br /> U Public Water System <br /> 9 different from Owner Water System Name Cartad Name or Phone Number <br /> TYPE Of WORK Vew well ❑ Replacement Well ❑ Well AkerationfModification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) S of bonngs ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION 5 - <br /> Driiling Maffwd'� a.Mud R 0 Air Rotary ❑Auger ❑ Cable Tool ❑ Push Pant ❑ Other <br /> Proposed Well Depth r ft Excavation I' in diameter ❑ Open Bottom Gravel PaWGravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor ng Depth ft <br /> Well Casing Diameter in 'Thictness/GaugetASTM Sched O Steel Plastic ri Stainless Steel ❑ Other <br /> Grout Seat Depth r ( eft ❑ Neat Cement(94 lb bag/5-10 gal water) j Sand Cement sack marl7 gal water <br /> Be ite%(20%saBds) ❑ outer p�1YMENT <br /> Grout PlacementMethod Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) RECEIVE® <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other NOV 1 C �1f!'9� <br /> 0 Concrete Pedestal❑Dlmensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Wt3teY Ld1Pl�I it <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT U E O LY Q� Q <br /> Application Accepted By --7f / Date Area / ` Employee ID# <br /> Grout Inspection By i f �cz.y rL� Date Z- ❑ SPECIAL Well Pemtit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> SON Boring l on By Date Constrrxaerl Well Depth ft <br /> CONJMENTSCS u7 i j • coy, <br /> -- <br /> PE SC Recelved Checks/ Amount Date Permit/ Invoice s Well IDN <br /> Info Cash 11 Remitted Service Request# <br /> q 0-5-11 <br /> 7 (47 1 i q <br /> EHW43-Orr 9W/= / _ _ /PW I of ,/ well/Puvq+P.MN <br />