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� d <br /> l 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 1� CRYRIP m <br /> CROSS STREET 1 V�`.1 hl� {l APN {��`� V V' ,�i V P(A'RCE\L.SI�ZE1`V��1•� LAND USE APPLICATION# p <br /> OWNER NAME -�' I V I 1 ��1J `rI'V PHONE <br /> OWNER ADDRESS CrrYISTATEIZIP i <br /> CONTRACTOR 1'rIV1 ;l►1S nY�►11N� Iri� PHONE 1ILM q�?1' I112k <br /> CONTRACTOR ADDRESS OIA 1 CRY/STATEIZIP M)U M ca 1 J l � 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STA <br /> T <br /> IpE <br /> ./ZIP <br /> LICENSE C-57 C-61 -- D-09 _] Other NUMBER 1 1, V % ExPIRATION DATE <br /> DOMESTIC WELL SAMPLING:"xGeneraI Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation!Agricultural - Industrial Water Quality Monitoring _ Soil Sampling/Characterization <br /> Public Water System <br /> If c1l orent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well _ Replacement Well 3 Well Alteration/Modificalion Other <br /> Monitoring Well(s) #of wells 0 Soil Boring(s) #of bonngs Geotechnical #of borings <br /> Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> ❑ New Pump Pump Replacement 7 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mudto Air Rotary -, Auger r Cable Tool Push Point Other <br /> Proposed Well Depth ft) ExcavationI�in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Condo torAasing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sch( Steel Plastic Stainless Steel Other <br /> Grout Seal Depth QZLI ft , Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i7 Other <br /> Grout Placement ethod Pumped Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor F Other <br /> Concrete Pedestal Dimensions:Width it Length it Thick <br /> �in Christy Box Stove Pipe <br /> PUMP SubmersibleL 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 /> MININIt'NI 24 HOUR AUWANC'F NOTICE REQUIRED FOR INSPECfiONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date %�y Zo?f' Area �� `? Employee ID# �� <br /> Grout inspection By - Til 'b-1 Date S ///� ZC�LS ❑ SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER ReCeivp <br /> Soil Boring Inspection By Date Constructed Well Depth ►—f-{ ME'N <br /> �ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info B Cash Remitted Date Service Request# Invoice# We <br /> � u� •?0'� E QUIN COU <br /> NtAt T pE AL <br /> FfiIY)._-pr,qi 0- Page lof: oaded into AccelaNcl!:PurtqPP:'n;ii <br />