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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT r,, CALk209 9 -7 97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �\ /f CITY/ZIPS _J l Cj� ` r t m <br /> CROSS STREET + ) N .-. ^(00 PARCEL SIZE / /y LAND USE APPLICATION# A <br /> �-(�-]n���(L� N <br /> OWNER NAME PHONEI �? <br /> OJI <br /> OWNER ADDRESS CITYISTATEIZIP 1 <br /> CONTRACTOR I PHONE /1 l / <br /> CONTRACTOR ADDRESS L� laiI CITYISTATE/ZIP <br /> SUBCONTRACTOR ti t 1 h PHONE \ <br /> SUBCONTRACTOR ADDRESSS�TE/Zl <br /> LICENSE C-57 ❑ C-61 ❑ D-09 L Other- NUMBE / ' L EXPIRATION DATE -`-"X" <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Pdvate C Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring L. Soil Sampling/Characterization <br /> _ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Nurnber <br /> TYPE OF WORK C New Well C Replacement Well C Well Alteration/Modification ❑ Other <br /> s <br /> C Monitoring Well(s) #of wells C Soil Boring #of borings <br /> Boring(s) 0 Geotechnical--�}y #of bortn <br /> C Out-Of-Service Well C Out-Of-Service Well Renewal ❑ Cross-Connection Repair 11 <br /> C New Pump VPump Replacement C Pump Repair ❑ Raise Well Casing S,4 2 <br /> 092 <br /> WELL CONSTRUCTIONy�tNA/ - QU/N C <br /> Drilling Method I Mud Rotary Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other ACTH ONr'7OUN <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom C Gravel Pack/Gravel Size �'Ttp meter <br /> - Conductor Casing in diameter 1 Conductor Casing Depth ft T <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel CI Other <br /> Grout Seal Depth ft !- Neat Cement(94 Ib bag/5-10 gat water) l Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) i= Other <br /> Grout Placement Method ❑ Pumped C Free Fall C Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor p Other <br /> C Concrete Pedestal DDimensions:Width ft Length ft Thick <br /> in !: Christy Boz C Stove Plpe <br /> PUMP ! Submersibles Turbine C Other HP Pump Set ft Standing Water Level -) ft <br /> Plot Plan Requirements. Attach a plot plan with the exact location of water well with respect to the folio-Ring 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 /> 0'1 ICE REQbih c_ iR iNSPECTiO3NS-PLEASE (209)95m-'1401i <br /> EPARTMENT U E 0 NjL Y22/J(^ <br /> Application Accepted By Date a �v ZJ Area Employee ID# /L/__ <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By ��t�>L��1 Dao fJ2(�Z WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS (_bL11--Ot3 'yWV-N <br /> PE SC Received heck#/ to Amount Permit] <br /> C des Info B Cas emitted D Service Request# Invoice# Well ID# <br /> gZ W/-'O O <br /> EHDn43-06 IWA17R022 Pugs I Dr 2 WC11/Pump Plmlit <br />