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DocuSig; Erroelope ID: 987E7C17-lD8F-4C3C-87BD-D02ED9CB5205 <br />1 WELUPUMP 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 EXPIRES1 YEM FROM DATE ISSUED <br />JOB ADDRESS 1-17MO Goran Vok-y ___ CITY/LP L4A%b,P t� `53t 0 <br />(CROSS STREETTa`4nL 4++krt pr 1 ^ APN I`i�i°ICyq PARCEL SIZE l'a 31 LAND USE APPLICATION# <br />OWNER NAME Rogmoro, D\Nt „ La <br />OWNER ADDRESS CID k lAO'CA10 YI\liS tw <br />___--- -_ PHONE____ _- <br />1� <br />�1� CITY/STATE/ZIP 1Ahr}w-L CA `RSS3 <br />CONTRACTOR 1441 o trs"A -• 6 l eff.'t-rs COn%t•11�+5 Co�•.�y -- PHONE ;tug� <br />1 4.1 <br />Y <br />CONTRACTOR ADDRESS RIDa 1"` kglr'kA` �`� CITY/STATE/ZIP �i � Q40 <br />SUBCONTRACTOR SAMS- PHONE �F- <br />SUBCONTRACTOR ADDRESS Set (V\ j)CITY/STAUTE21PW� <br />LICENSE t C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 6( 00 ` EXPIRATION DATE 5/34 120'23 <br />DOMESTIC WELL SAMPLING: ❑ General MineraMoliforrn Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ DomestictPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ;K Soil Sam piing/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 D Well Alteration/Mod ifica bon ❑ Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings tK Geotechnical <br />U Out -Of -Service Well ❑ Out-Of-Servioe Well Renewal ❑ Cross -Connection Repair <br />New Pump - Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br /># of borings <br />Drilling Method Mud Rotary a Air Rotary )9 Auger ❑ Cable Tool Push Point Other <br />Proposed Well Depth 25%50_ ft Excavation _ 6" in diameter �] Open Bottom ❑ Gravel Pack/Gravel Size _ in die <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel a Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth A- S � S O ft A Neat Cement (94 Ib bag75-10 gal water) D Sand Cement -sack mix/7 gal <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall A Other 'l''tltm-P- ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />❑ Concrete Pedestal DDimensions: Width _ <br />In ❑ Christy Box ❑ Stove Pipe <br />❑ Other <br />ft Length <br />It Thick <br />EE ❑ Submersible❑ Turbine ❑ 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 />MININIVINI 24 HOUR ADVANCE NOTICE, REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By - —�� G Date L /3 03. _ Area -3 Lit k f OF Employee ID# 4.5 <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By _ Date ❑ WAIVER Received PAYM <br />Soil Boring Inspection By Date a- Constructed Well Depth �" <br />COMMENTS -Azq Ar <br />Arse <br />M <br />9 <br />v <br />m <br />y <br />EHDo43-0610/25/202 t Page 102 well i Pump p=Mft <br />