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WELLIPUMP PERMIT <br />1868 EAST HAZELTON .vEN,,-STOCKToN CA95205 - (209) 468.342 <br />Ex�lRES i YEAR FROM DATE ISSUED <br />SAN JOAQUIN COUNTY ENVIRON.FHTAL HEALTH CE CALL T 31953 INSPECTIONS -_ <br />NON-REFUNDABLE PERMIT CRYRIP <br />- <br />JOB ADDRESS LAND USE #�� <br />• O w /Syr �cL SQE �-- /� 11/VVAw <br />Lo APN � //�� <br />CROSS STREET 1 , _ 1 AL%1 U111 I • r PIONE_�; j L. 1'���w <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS 23 575 <br />LICENSE C-57 C-61 C <br />DOMESTIC WELL SAMPLING: ❑ General <br />INTENDED USE DomesticlPrivele -, <br />Public Water System <br />0 ddfurent from Owner <br />Contact Name or Plbrm Number _ AR <br />TYPE OF WORK t 1 New Well Replacement Well - Well Alterallon/Modification � cps er - ,!�/Geotechnical S X r ✓lO��IN v` <br />1 Monitonng Welln o <br />Wallis) # of wells o Soil Boring(s) N/y)ECD(/� <br />Out -Of -Service Well a Out -Of -Service Well Renewal Cross -Connection Repair DEp�'F/VTTAC. <br />New Pum Pum Replacement ; ; Pum Repair Raise Well Casing <br />-i�ELCCONSTRUCTION <br />___ <br />WELL CONSTRUCTION C�3� G O <br />Drilling Method Mud Rotary Air Rotary f(uger Cable Tool Push Point �ther n diameter <br />Proposed Well Depth &- ft Excavation in diameter Open Bottom Gravel PacJJGravel Size <br />Conductor Casing in diameter I Conductor Casing Depth tt <br />Steel '. Plastic Stainless Steel Other <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Sched sack mrx/7 al water <br />Grout Seal Depth a ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement g <br />Bentonite (20% solids) Y01her <br />Grout Placement Method i-, Pumped .i Free Fall 1( Other p,PIY►1 p _ Retardant I Accelerator (name) <br />PEDESTAL Installed By :: Driller ;I Pump Contractor i Other - <br />U Concrete Pedestal -,Dimensions: Width it Length h Thick <br />�in i 1 Christy Box stovepipe - <br />PUMP— <br />---Submersible'-, Turbine C Other HP Pump Set R Standing Water Level_ <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 propem, lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINISIL NI 24 IlclllR AI)VANCE NOT'Ier. REQUIRED FOR I:NSPEC.1-IONS - Yl t.ASE (.'AIA. (209) 953.7,697 <br />DEPARTMENT USE r0NLY <br />-mois�,�oZ <br />Application AcceptedZ— Z-- /� <br />By �/`—Date — <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Ingpeclion By L' <br />CC1tAMEN in �1 P <br />,S <br />Date <br />Date <br />t C <br />Lam, } ry f aP E <br />Area 3 mployee ID# <br />❑ SPECIAL Well Permit <br />❑ WArvER Received <br />—02-/ Constructed Well Depth <br />ra <br />PE <br />Codes <br />.37-7 <br />SC Received]�Check#1 Amount Date Permit/ Invoice # <br />Info 8 Cash Remitted Service a uest # <br />_ SO 2 <br />WeII ID# <br />--- -- <br />----- ----- <br />fytq23T�, <br />