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EMAILED <br /> 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 /> .JOB ADDRESS [C I e ]a' i.u, A- - �+1(— CITY/ZIP rq--t't 14r 1 �., �/3 LA <br /> CROSS STREET �]�1M -1ftL APN -1'J �%- p /j o <br /> i— i 1 PARCEL SIZEi 1y LAND USE APPLICATION# vp <br /> OWNER NAME K n 1 L) PHONE/j t <br /> OWNER ADDRESS It,, CITY/STATE/ZIP <br /> CONTRACTOR &L 1 t�/�C �1I �' -x l 11 (y jg PHONE V It Ct"� <br /> CONTRACTOR ADDRESS :> 1."- L)c- 'el 0 CITY/STATE/ZIP(,?-kVlt6 ci f)K- J K 7 <br /> SUBCONTRACTOR tI �` PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 LI Other NUMBER - EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Cofiform Bacteria(4391) Dibromochforopropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricuitural J 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 U Well Alteration/Modification !I Other <br /> Monitoring Well(s) #of wells !i Soil Boring(s) a or borings Geotechnical /b°�ri p <br /> ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal LI Cross-Connection Repair CRg <br /> New Pump Pump Replacement D Pump Repair ❑ Raise Well Casing �m�J <br /> WELL CONSTRUCTION f <br /> Drilling Method KMud Rotary Air Rotary _ Auger Cable Tool Push Point -' Other SA)V j <br /> Proposed Well Depth ft Excavation ,.)�— in diameter F Open Bottom kGravel Pack/Gray t�J �rer <br /> Conduct r Casing in diameter / Conductor Casing Depth k `rJ'f`7( ,^a^:% T}i f Y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Q---2: Steel % Plastic - Stainless Steel Other Grout Seal Depth 'C'f'`�,(� - Neat Cement(94 lb bag/5-10 gal water) Li Sand Cement sack mW7 gal w t— <br /> ater <br /> Bentonite(20%solids) _- Other <br /> Grout Placement Method Pumped L I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By <Driller - Pump Contracto - Other <br /> Concrete Pedestal _Dimensions:Width ft Length ry ft Thick <br /> �in Christy Box Stove Pipe <br /> PUMP )(Submersible Turbine L 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 /> 1;.1`:t4I *,i_24Ill}( itAlit :e( i.`GCSIR.LRI_QtIRIA) 101; 1N.tiVCt IONS-PI.LJLS :CALL I2(i9)953-7:697 <br /> D1132PAARTMENT USE/ONLY <br /> Application Accepted By Dale Area Employee ID# <br /> Grout Inspection By Date !... SPECIAL Well Permit <br /> Pump Inspection By Date lll — I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> CSMENT,S <br /> Z-juL?"jT k�ft Loci- <'7o- <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Lnfo By,, Cash Remitteo Date Service Request# Invoice# Well ID# <br /> 19 2 <br /> 61(17 2 Zy <br /> H11x043-05 04/07J2022 222,2� 8/L.L Pa6<1 of W01 Pump P—it <br /> 7 pioadea i to Accela <br />