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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _I SS'S3 F'ey '� C44m,7 `�jLI - CITYIZIP q5-3(04:7 !4 Q/� q - <br /> =a <br /> m <br /> CROSS STREET APN -�3 Fk_ —Q / PARCEL SIZH/'t!�ZLAND USE APPLICATION# <br /> OWNER NAME I Y I Q�Qit y v <br /> OWNER ADDRESS a,W4// CITY/STATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS l Ci1TY/STATEIZIP ' ,1` ! �' " n')- <br /> SUBCONTRACTOR _ PHONE <br /> I <br /> SUBCONTRACTOR ADDRESS CITYISTATE2IP _ <br /> .1 e <br /> LICENSE ❑ C-57 C 61 _❑ D-09 ❑ Other NUMBER 1,1-�p.��2"i F EXPIRATION DATE "0 <br /> DOMESTIC WELL SAMPLING:O General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) A <br /> `INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization14;r- <br /> If <br /> ❑ Public Water System �c' � <br /> It ditierent from Owner Water System Name Contact Name or Phone Number O <br /> TYPE OF WORK ❑ New Well eplacement Well ❑Well Alteration/Modification ❑ Other RA. <br /> a?3 <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑Geotechnical #of tZp q <br /> ❑ Out-Of-Service We ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �F4t IRoA/N C <br /> ❑ New Pump [D�Pump Replacement ❑ Pump Repair _ ❑ Raise Well Casing p �N oEpq� ry <br /> Civ <br /> WELL CONSTRUCTION ( FNT <br /> Drilling Method ❑Mud Rotary El Air Rotary ❑Auger ❑ Cable Tool CI Push Point 11 Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacklGravel Size in diameter <br /> ❑ Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seat Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other I <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller WPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width _ft Length_ ft Thick <br /> in ❑ Ch45.ty Box ❑ Stove Pipe <br /> PUMP ubmersible❑Turbine ❑ Other HP 2 Pump Set-L,2 L4 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 Iines, 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 /> ••a• 9 ?q T t• NOT_ er E B II4rSPE NS F�! (2 .i_76 / <br /> Ei:;��';tue�Jt.�24 IIfle1�a�.��r';'•;GG 4:,%g,;,�?Is'Its:.li 170 SS a..o_""-'�%�iat�. ••�3.�..r1✓~;d;,S�PJ tt.`%)>:F` ;� <br /> E <br /> DEPARTMENT SE 91NLY 9 /� <br /> npplication Accepted 8y Ds-.ie / Area i Employee ID# <br /> Grout Inspection By Date ❑ 5PEGIAL VIre11 Permit <br /> Pump Inspection By � Date /7�6. ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check#I Amount Permit/ <br /> Codes Info B C s emitted date Service Request# Invoice# Well ID# <br /> HID043-06 10!251202I �/► /' /�� 1/���� Page 1 of 2 Well/Pump Permit <br />