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y EMAIL.ED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIrRES� 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP 1 V r/1 C(J,�:> m <br /> CROSS STREETFLOdON APN 11 V I D D PARCEL SIZE LAND USE APPLICATION# O <br /> /+ C t,� i (� m <br /> OWNER NAME VI PHONE 1 W�1 9 in <br /> � <br /> OWNER ADDRESS �1�WC�tJl CITY/STATE/ZIP r CONTRACTOR I 1 �II G (b <br /> L '\PHONE 1�J <br /> CONTRACTOR ADDRESS I �r CITY/STATE/ZIP (1U IM <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATE/ZIIP//� <br /> LICENSE C 57 C-61 .1 D-09 Other NUMBER EXPIRATION DATE <br /> DOMEsnc WELL SAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE omestic/Private , Irrigation/Agricultural -_ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) fr of borings Geotechnical #Of borings <br /> !l Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair _ _Raise Well Casing <br /> I WELL CONSTRUCTION <br /> 'Drilling MethodAAud Rot 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 /> J Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamet r in Thickness/Gauge/ASTM Sched,zn V SteelPlastic . Stainless Steel Other <br /> Grout Seal iz <br /> th ft i; Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> entoni a(20%solids) a Other PA!Grout Placement Method,, Pumped 1-1 Free Fall Other Retardant/Accelerator(name) E Y <br /> Ll <br /> PEDESTAL Installed y Driller Pump Contractor ..I Other <br /> Concrete Pedestal I-0imenslons:Width ft Length ftThick Tj 123 <br /> j in ❑ Christy Box Stove Pipe <br /> -IN JOA TY <br /> -N VIF�ONM1 7 <br /> PUMP ❑ Submersible Turbine Other HP Pump Set fit Standing Water Level to ai TH i <br /> Plot Plan Requirements: Attach a plot plan with the exact location of grater 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 /> AININILM 24 HOUR ADN ANCL\OI ICE REQUIRED FOR INSPEC I IONS-PLEASE CALL 1209)95: <br /> 77 DEPARTMENT US O LY <br /> � 9 y3 <br /> Application Accepted By= Date Area Employee ID# <br /> '`Grout Inspection By Date ?Z----Z 3 ❑ SPECIAL Well Permit <br /> WP2'5Dj�Yump Inspection By Date 2 [ WaVER Received <br /> Soil Boring`Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check#! Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cas Remitted Service Request# <br /> kg� v 3 <br /> 9i iss- o <br /> IL <br /> 6 <br />