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EPA ED 1 WELUPUMP PERM ` 2 El" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED w �( fQJ y S� Q1 Q f JOB ADDRESS � a ,� �� dJI CITY/ZIP N � / ° � b®• m CROSS STREET %�(.lid�• �OIG/�jAPN S��C Zd rD� a,f'' o /` ` ru2CEL SIZr�•/Z _yaND USE APPLICATION# A OWNER NAME S•a LTyr*,WS1+ " PHONE I ` 'a®f-Q�C ��7b ai OWNER ADDRESS S • l��rrr CITY/STATE/ZIP CIP0010A"e 64 q- CONTRACTOR LL /I� ��` PHONE/ `.20 B- CONTRACTOR ADDRESS / &ej T h ePr- CITY/STATE/ZIP st N®.e.4I coll SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ��CIITY/STTATE/ZIP �s LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER `T/1,7 y 9 EXPIRATION DATE / DOMESTIC WELL SAMPLING:,KGenefal Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)C.,Arsenic(4393) INTENDED USE Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well 0 Replacement Well XWell Alteration/Modification 0 Other lWfe G 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ &otechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 0 New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casio WELL CONSTRUCTION Drilling Method 0 Mud Rotary A Q(Air Rotary ❑ Auger ❑ Cable Tool Cl Push Point 0 Other Proposed Well Depth_4 _ft Excavgf on . in diameter 0 Open Rnttom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor C�/ng_*aft ��r diameter / Conductor Casing Depth •17c,ft Well Casing Diameter. -5 . Thickness/Gauge/ASTM Sched /j! ❑ Steel Plastic 0 Stainless Steel 0 Other Grout Seal Depth O♦*0 ft 0 Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mix17 gal water • X Bentonite(20%solids) ❑ Other Grout Placement Method Pumped 0 Free Fall Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other ❑Concrete Pedestal ODimenslons:Width ft Length ftThick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑Turbine ❑ Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a"plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads,,existing wells, structures, potential sources of con tamination,.sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. tytlN0,11INI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USE ONLY Application Accepted By Date_6e2-20L,�_ Area Employee ID# §� Grout Inspection By ate �9 _ ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well epth COMMENTS �E��l..� {_Xi _ ' ' e 212 IM NoiLM110 PE Sc Received Check#/ Amount Date Permit Invoice# Well ID# Codes Info B ash Remitted Service Request# i v oa $ �2 Zs P25 mma 2 B14DO43-06 04/07/302-1 n_ / �j'J��J" �j Parc I of 3 Well/Pump Pcnnit Uploaded into Accela