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c EN1A� ED 1 WELUPUMP PERMIT A�_2 cin SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186 AVEN E- KTON 95 05-(209)468-3420 NON-REFUNDABLE PERMIT I CALL 209 953-7697 FOR INSPECTIONS EXPIR YEAR FROM DATE ISSUED JOB ADDRESS 1 C �4 L V L(-)S R D. C"IZIP Ledo S•�� CROSS STREET \GN V ' D• APN ��I C�.c G;-o PARCEL SIZE J• �1 LAID USE^7APPL(ICATION# A OWNER NAME -1 (,� �!l�rC t ��St I'1 C (t1y,�' r PHONE O'r C' I �U 5 Q�L13 frn OWNER ADORESS A*J"i,, �(jnG�`J``� Gp�`/G _ CITYISTATE/LP_�1��1i ao 95�7 CONTRACTOR \1 n II I f� }�D^ I 1 1 n 1 PHONE .f0/9-3(gq-- a7-19 CONTRACTOR ADDRESS I G LJ C . CRYISTATEMP C^�� I A-r CIL� 1 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CtTYISTATE/Z!P �Z LICENSE 'C-57 :J C-61 LI D-09 L'Other NUMBER L .L EXPIRATION DATE 7 j 1 1 - DomESTiC WELL SAMPLING)eCeneral MMnerallColifonn Bacteria(4391)><Pibromochloropropane(4392) Arsenic(4393) INTENDED USE DomesticlPdvate Inigation/Agricukural ,1 Industrial Water Quality Monitoring Sod Sampling/Characterization Public Water System If dirtererd from Owner. Water System Name Contact Name or Phone Number TYPE OF WO ,New Well I Replacement Well Well AlterationtModification -1 Other ENT Monitoring Well(s) #of wells Soil Boring(s) x of boringa _ Geotechnical a or oonngs �I1 i�D Li Out-Of-Service Well Out-Of-Service Well Renewal A Cross-Connection Repair I I r ew Pump ! PumpReplacement PumpR Raise Well CasingM Y [] WELL CONSTRUCTION BAJV J 24?5 Drilling Method)(Mud Rotary 1 Air Rotary L'Auger U Cable Tod ❑Push Point :1 Other 7f��q N Proposed Well Depth CU ft Excavation in diameter Open Bottom Y'Gravel Pack/Gravel Sae 1/ vop -_ Conductor Casing in diameter / or Casing Depth ft ' � Well Casing Diameter (�p In Thickness/Gauge/ASTM Sched CA.�C<- ;; Steel 7S Plastic -_.Stainless Steel Otter Grout Seal Depth 'C' ft Neat Cement(94 lb bag15.10 gal water) ')L,Sand Cement 10 sack mixr7 gal water f i Bentonhe(20%solids) _ Other Grout Placement Method A Pumped i Free Fall 7! Other D Retardant/Accelerator(name) PUESTAL Installed By riller -1 Pump Contractor n Other :'Concrete Pedestal 01menslons:Width 5 ft Length_�ft Thick lin Christy Box Stove Pipe uMP Submersible!Turbine Other HP___3 Pump Set CS it Standing Water Level 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 contamination,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. V IN 24 ItOf:R ND)\%N(I. No I( I-Rt.Qt IRED IOR INS Pt( I IU\ti-PI I.-"L('.U.1.t 209(953-7697 DEPARTMENT USE ONLY Application Accepted By •Soul Date "�� Area �_ Employee ID#_�[S Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date AXf J, WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ctlectaH Amount PermiU Codes Info B Cash Remitted Date Service Re uest# Invoice# Wall Ili So 3P-0 5.1(P-25 A P a a z /� — 06-1 I74•cd AP250 2 0 5 F1111043.0e owTrzozz �iy_ �� „^' 1 / ��U� r.�:t orz ----- (%.n i r..,p rim: