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1 WELL/PUMP PERMIT Cwu InRni uw� /'nn.�ry Cu.non.�..ourwi 4Jvw� Tu rlrnwor.. 40co M.— U.— r.... w--- Cr...., /`n A—C 1—M wco I- NUN-KEFUNDABLE PERMIT SC Received K2 Info Cash ALL 209 953-7697 FPR INSPECTIONS F-X/}P�IKE5 1 YEAR FROM DATE ISSUED TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 2.25.22 ADS 3� I�- ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical Flaugiveo - ;?0 JOB ADDRESS ❑ New Pum Pum Replacement ❑ Pum Repair ❑ Raise Well Casing CITY/ZIP �"' '6' nn CROSS STREET f'�lLt wl Q n 0 / APN O10 PARCEL SIZE 341 I Z LAND USE APPLICATION�# ❑ Conductor Casing in diameter / Conductor Casing Depth ft NT Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other N OWNER AME sack mix/7 gal water PHONE Cq0q_z' ZC/l_ 47 6 Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) L06D OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR C /� — r/ D PHONE (J CONTRACTOR ADDRESS CITY/STATE/ZIP qe SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS (N' ICITY/STATE/ZIP LICENSE g C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE d If UUIVIE51IC VVELL JAMPLING: L 1.7eneral IVIlnerauuoiliorm tsaciena (4Jy I) u uiDromOCnioropropane (43yL) L Arsenic (43yS) INTENDED USE )(Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System SC Received K2 Info Cash If different from Owner: Water System Name Contact Name or Phone Number 0A 'Lon TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 2.25.22 ADS 3� I�- ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical Flaugiveo ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair FEB ❑ New Pum Pum Replacement ❑ Pum Repair ❑ Raise Well Casing WELL CONSTRUCTION SAN �OAQUIN Drilling Method El Mud Rotary Li Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other COUN Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SMALI ter ❑ Conductor Casing in diameter / Conductor Casing Depth ft NT Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINrMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 D ARTMENT US O Y Q Application Accepteay Date Area Employee ID# Grout Inspectio Date ❑ SPECIAL Well Permit Pump InspectioDate 41116(zeZZ ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS T PE Codes SC Received K2 Info Cash Amount Date Permit/ Invoice # Well ID# Remitted Service Re uest # 3�� LS't, 2.25.22 ADS 3� I�- EHD043-06 10/25/2021 Page 1 of 2 Well / Pump Permit