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EMAILED <br /> 1 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � � CrrY1ZtP m <br /> i) � 0 r/ <br /> CROSS STREET * I APN � �� I I�/' � �J�V PARCEL SIZE � LAND USE APPLICATION# A <br /> OWNER NAME �J,' IG X) \j I/� i PHONE `V% ���� y <br /> OWNERADDRESS % rV� 1 1'� CMISTATE/ZIP ✓`�T I -I / �j�n <br /> CONTRACTOR t � I ,ISli ` PHONE 7-0 <br /> CONTRACTOR ADDRESS I / CfTY/STATE/ZIP Y/ UlD 953 /7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATEJZIP <br /> LICENSE C-57 C-61 0-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural _i Industrial Water Quality Monitoring Soil Sampling/CharacterizatigS^t' <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification = Other V4D <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of bonngs Geotechnical # � D <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair SAN O ZQ� <br /> New Pum _: Pump Replacement a Pump Repair Raise Well CasingJp <br /> WELL CONSTRUCTION R C <br /> Drilling Method Mud Rotary Air Rotary __ Auger. G Cable Tool Push Point Other EA�TN D PA 1' <br /> Proposed Well Dep th �ft Excavation ��in diameter - Open Bottom X Gravel Pack/Gravel Siz in diame <br /> Conduct n diameter / Conductor asing Depth ft <br /> Well Casing Diameter to Thickness/Gauge/ASTM Sched � Steel 'Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> 'Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller - Pump Contractor P Other <br /> t- Concrete Pedestal-Dimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> POMP Submersible; Turbine 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,pro-Ode location of any water wells or surface water within 200'radius of proposed well. <br /> NIININIUNI 24 HOUR.ADVANCE NOTICE REQUIRED FOR INSPECTION'S-PLEASE CALL.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date //!!sh- 7 Area J / Employee ID# <br /> Grout Inspection By - Date S! `�/ Zl-( ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil BorinWn pection By Date i Constructed Well Depth ft <br /> COMMENTSt" <br /> �r Jri+c 2 Z u G VJPN t>< <br /> PE SC Received CheckW Amount Date PerrnW Invoice# Well IDS <br /> Codes Info B ash Remitted Service Request <br /> Z <br /> EHDbl3.0600/07RR22� i// I�crg0("(,12— Page 1or2 Well r Pump?am <br />