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WELUPUMP PERMIT i' V- 4 <br />SAN JOAQUI14 COUNTY ENVIRONIAENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE- STOCKTON CASS205 • (209) 468.3420 <br />NON-REFUNDABLE PERMIT CAi_1 t9ri 953-7847 rno ELieoernnrde CYOIDCC 4 Vee -,o,-... n,.r,- <br />JoBAoti 4955 West Lane C c,,rLPStockton 95210 <br />CROs SLREET E March Ln APN 10+ r 160 • J PARCEL SIZE -0 .-AND UsE APPuaknON n <br />OMERNAN.E Family Pet Hospital/,)dhn WIA fzaMI1V LWNEI415-470-2424 <br />ONNER ADDAESs:'4 9 5 5 West Lane CITYISTATE/L Stockton C A 95210 <br />CONTRACTOR Pur(Box <br />Drillers, Inc PHONE 209-887-3554 <br />CONTRACTOR ADDRESS PO ,7 C X 6 4 CITY/STATFJLPL i it d e n, C A 95236 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITVISTATEOP <br />LICENSE X C -5T U C-81 ❑ D-1 n Other NUMBER 377923 E)MRAn0N DATE 7/31/19 <br />DOMESTIC WELLSAMPUNG: 7 General Mineraticc form Bacteria ;4391) C Dib ronnochloropropane (4392) - Arsenic (4393) <br />INTENDED USE 0 DomestofPrivate 0 ImgationrAtldculilrral C Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterzalion <br />0 PublicWater System &P <br />I(dirWem from Owner. filer System Nacre Ccrtaa Nacre °r Phme Number <br />TYPEOF WORK 0 New Well D Replacement Well C Well Alteration/Modi ication C Other <br />7) Moniloring We6(s) # of wells 0 Soil Boring(s) R °{Q-fms = Geotechnical ar or b°nnys <br />CJ Oul-Oi-Service Weir C Out -Of -Service Well Renewal C Crass -Connection Repair S <br />0 Ni um Replacement Cl Pura Repair 0 Raise Well Casing SAN JOq <br />WELL CoNsTRucri NLVV <br />T RON <br />Drilling lftthod n Mud Rotary 0 Air Rotary 7 Auger ❑ Cable Tool n Push Pant n Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom 17' Gravel PackfGravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thick nesslGauge/ASTM Sched D Steel D Plastic 0 Stainless Steel �j Other <br />Grout Seal Depth_fl 0 Neat Cement (94 /b bag/5-10 gal water) C Sand Cement sack tWxi/ gal wafer <br />0 Bentonite (20% solids) 11� Other <br />Grout Placement Method C Pumped O Free Fall ❑ Other 0 Retardant/Accelerator(name) <br />PEDESTAU Installed By 0 Driller E Pump Contractor 7 Other <br />C Concrete Pedestal nDlmensIons: Width f <br />