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419MAI ED F,)qW Z,-I, �Yq- 3113 <br /> 1 1!�- pal <br /> 1 I WELL/PUMP PERMIT <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 EXPIRES'I YEAR FROM DATE ISSUED <br /> VV l�1 �`A N <br /> JOB ADDRESS I 9 J '`+ �•/�}V 1 rj y CITYIZIP LC;C�I i y �) °K m <br /> CROSS STREET LQ C ,\ KIT APN C LSC"I O `"I�[.^ PARCEL SIZE`A'A LAND USE APPLICATION# A <br /> OWNER NAME )G�r� 1 1' '(14NPHONE vy,+ <br /> OWNER ADDRESS ,�I�,�•.J �. Y-e C. -e n+ Nit CITY/STATE/ZIP L.-�. 1 i <br /> CONTRACTOR V nj 1'C I II'f 1A,1 1 1� r1 PHONE �/L ��" 1' �{-77q <br /> CONTRACTOR ADDRESS .0 63C' CITYISTATE/ZIP GCil <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q <br /> LICENSE 74.0-57 1 C-61 D-09 -1 Other NUMBER-3u 3 EXPIRATION DATE 7-31 - 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391))COibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domesti Private :_J Irrigation/Agricultural ;J Industrial A Water Quality Monitoring Soil Sampling/Characterizat' Q <br /> Public Water System Y/Y//fin <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well '-I Replacement Well Well Alteration/Modification F1 Other D <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical # S, 7202,) <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair SA <br /> IV <br /> )(New Pum -1 Pump Replacement Pump Repair :1Raise Well Casing <br /> l JCA <br /> WELL CONSTRUCTION HEARTH NMENT Ty <br /> Drilling Method Mud Rotary Air Rotary i Auger I Cable Tool I Push Point Other DEPARTM T <br /> Proposed Well Depth ?J ft Excavation 2 in diameter D Open Bottom )(Gravel Pack/Gravel Size )/4— in diameter <br /> ConductorCasing in diameter / Conductor Casing Depth ft <br /> f <br /> Well Casing Diameter 4' in Thickness/Gauge/ASTM Sched ( 2k'. ❑ Steel $Plastic -I Stainless Steel Other <br /> Grout Seal Depth X66! ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> F Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped '..i Free Fall 1.1 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Cl Pump Contractor, _i Other <br /> Concrete Pedestal:;Dimensions:Width -1 ft Length J ft Thick <br /> �in Christy Box L Stove Pipe <br /> PUMP Submersible? Turbine -1 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 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 /> DEPARTMENT US ONLY �( <br /> Application Accepted By Date /� /7 ZZ Area gq 9 Employee ID# +` <br /> Grout Inspection By Date 3 SPECIAL Well Permit <br /> Pump Inspection By N►Ia1 Date J 1!j _2, WAIVER Received <br /> Soil Boring Pspection By Date Constructed Well Depth ft <br /> COMMENTS(OR" L4/1i,LJ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes InfoB Ca h Remitted Service Request# <br /> 3 O Zo <br /> 8o OS/ /S 7 <br /> 9 SS <br /> LUD043-06(W0720,2 Page I ort Well/Pump Permit <br />