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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 /> 1 � <br /> JOB ADDRESS i S,�t �,va rs Jew CITY/ZIP m <br /> A L D <br /> CROSS STREET N'J Q a W% 0 APN 3 J l�O ✓''`PARCEL SIZE�I �,5 LAND USE APPLICATION# <br /> Ca l C`l �`� 1 rfi , t� 1, �� m <br /> OWNER NAME Q ptP O [ PHONE O SQ°1 N <br /> L• c.c � c.i. t�C t�r v� �? <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR "'2„�/`;���,/ D�/Z11\FBI-=�n�p, �y,�L' PHON1E �y1�6� �L��2�+�C <br /> CONTRACTOR ADDRESS ;J a lam.1'r o%_ CITY/STATE/ZIP 1 V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTZ-5 <br /> DRESS CITY/STATE/ZIP ^ <br /> LICENSE - C-61 D-09 ❑ Other NUMBER '134 q< EXPIRATION DATE <br /> DOMESTIC WELL SA 7UNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ 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 ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings , ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 4•110 ft Excavation 2-4� in diameter ❑ Open Bottom Wdravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Cond ctor Casing Depth ft <br /> Well Casing Diameter , in Thickness/Gauge/ASTM Sched�-1 ❑ Steel [Rwslic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth O O ft ❑ Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> P-9'eentonite(20%solids) ❑ Other <br /> Grout Placement Method 9-Kmped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑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,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 /� <br /> DEPARTMENT USE ONLY 10 <br /> Application Accepted By Date 7i d' Area V 7 ` Emplo ''11 <br /> Grout Inspection By Date Z SPECIAL ell it <br /> Pump Inspection By Date WAIVER rived <br /> Soil Boring Inspection By Date Constructed Well ft <br /> COMMENTS <br /> T )y <br /> PE SC Received ec Amount Permit/ <br /> Info B Date sh, Remitted Service Request# Invoice# Well ID# <br /> EHD043-0604/07@022 (/1 2P 0�/ age]of2 Weli,Pump Pcrna� <br />