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IV ftl9Sta9 <br />I WELUPUMP PERMIT <br />SAA JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVIJIY-KEFUNIJAULE PER-MIIT,� BALL LU>i VW-10WFOR INSPECTIONS r-ArlKtS 7 TEAR FROM DATE ISSUED <br />Q�CS <br />JOB ADDRESS 397 !♦ L-Vy A✓, cITr21P 5fo,, &4o ✓ 45'A0(0 <br />CROSSSTREET S. 054A A✓t. APN i75Q&1d) y PARCELSMEA.3�LANDUSE APPLICATION# <br />OWNER NAME J7UL.KTOW 'AV > 4& HevT/At7,e nry�S PHONE <br />OWNERADDRESS Rc;_ C3ox 30a 31 CITY/STATEIZIP 5i601,1V. l'A 15.Z1.3 <br />CONTRACTOR 1ye:1 Q /m/e/imA%i A dud n&,N7 / PHONE' 3(G7 --.7b / <br />CONTRACTOR ADDRESS 90 1 XlVdVsf�:'n I w,o.. CITY/STATE/ZIP 1(111, (:A <br />SUBCONTRACTOR SAMC ills P%V`° PHONE S4.tf AS Above. <br />SUBCONTRACTOR ADDRESS r <br />LICENSE )C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />CITY/STATEIZIP <br />NUMBER "qOG EXPIRATION DATE- <br />DOMESTIC <br />ATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE D DomestictPrivate ❑ Inigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/Charecterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK r New Well ❑ Replacement Well C Well AlteratlonlModlficadw ❑ Other <br />❑ Monitoring Wells) # of wells Soll Borinto s of borings <br />:1 Out -OF -Service Well �i Out-OfServIce Well Renewal <br />A Geotechnical �_#ofhorfngs <br />❑ Cross-Connectlon Repair <br />New Pump ❑ Pump Replacement , Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth S -Sc It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth .6- 5o,' ft I9 Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement sack m1x/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />(trout Placement Method ❑ Pumped 18 Free Fall F Other r-em,'C Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length ft Thick <br />In ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set It 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 limes, 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE <br />1 ONLY <br />Application Accepted ByQJDate z-7 Z— <br />Grout Inspection B <br />Pump Inspection By <br />Soil Boring Inspection By L <br />COMMENTS <br />Date <br />Date <br />Date <br />Are, l Iq q Employee ID# AS <br />0 SPECIAL Well Permit Pq <br />❑ WAIVER Received 9 <br />Constructed Well Depth <br />N <br />m <br />g <br />m <br />m <br />EHDO43-06 1025/2021 Page 1 ort Well / P=p Pamit <br />