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e <br /> EMAILED <br /> g \2`2t� G,M <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 /> VIP; 1�1 q���L0 <br /> JOB ADDRESS Crrr/ZIP m <br /> �f' D <br /> CROSS STREET APN - I r PARCEL SIZE F�7-VLAND USE APPLICATION# <br /> VV�, GV PHONE vi-V✓ - <br /> OWNER NAME yX� ion <br /> CONTRACTOR <br /> OWNER ADDRESS 1 V I N �f -v CRY/STATE/ZIP��A io r <br /> CONTRACTOR I 1 1`� r PHONE <br /> CONTRACTOR ADDRESS I� CfTY/STATEIZIPMi 0-t1�1/ <br /> /J� 1Jt, <br /> [ \ <br /> SUBCONTRACTOR 1 PHONE <br /> SUBCONTRACTOR ADDRESS CITYr/STATEIZIP tr�fG�.1- /��Il11 7 r 1 <br /> LICENSE C-57 _ C-61 D-09 Other NUMBER ` '��� EXPIRATION DATE �/ ►'-r/ -L! -- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <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 D Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells D Soil Bonng(s) n of borings _ Geotechnical #of borings <br /> Out-Of-Service Well rl Out-Of-Service Well Renewal Cross-Connection Repair <br /> D New Pump Pump Replacement Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary, Air Rotary F1 Auger���� Cable Tool Push Point _ Other <br /> Proposed Well Depth: 11 ft Excavation —in diameter Open Bottom Gravel Pack/Gravel Siz in diameter <br /> Conductor Casing in diameter ! Conduct r asing Depth ft <br /> Well Casing Diameter 'I in Thick nesslGauge/ASTM Schad j, Steel 'KPiastic Stainless Steel Other <br /> Grout Seal Depth I Ci U ft Neat Cement(94 lb bagi5-10 gal water) Sand Cement sack mix/7 gal water <br /> �'Bentonite.(20%solids) Other <br /> Grout Placement Method umped Free Fall Other Retardant/Accelerator(name) PAYME <br /> PEDESTAL Installed By _ Driller Pump Contractor Other RECEr <br /> Concrete Pedestal -Dimensions:Width ft Length ft Thick <br /> �in Christy Box - Stove Pipe ` <br /> yL <br /> PUMP Submersible.- Turbine - Other HP Pump Set ft Standing Water L I ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followfig�J <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing FlBd�sFFF <br /> PIT <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 /> `:uAINILll 2.4 li(it R A[A "A(_[ Ac3l1(F.RFQIt IRED I-OR I IIONS-PLEASE CALL 1209)953-7ov- <br /> DEPARTMENT US O LY <br /> L <br /> Application Accepted By Date v 2 Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info my C Remitted Service Request# <br /> q37 f 18-0 i 12u 11P'LyCiCi �; <br /> 1 1 <br /> Effl)013-0604:0720;yf/ j l ✓ vag�I orz �[ �� Nkcll Pu^W Pc—1 <br />