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1 WELL/PUMP PERMIT
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Eau HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420
<br />NOPJ-REFLINDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
<br />- . cm ',alp .S -b trik-40^ CA 9'5.206 Jos ADDRESS ?o 2-8" /1) om Dr. D ,Y ,
<br />CROSS STREET IA). (ftia4•41621Vt• SA • APN11:5, —0 2.0 - te PARCEL SIZE ?Y`?A.at&E APPLICATION #
<br />OWNER NAME 8 ay ot-e crit Mowitt_ Caries PHONE 9E7 775 — 778
<br />OWNER ADORESS Rho/ Paseo Atasiegia, NE STE, 8 CITY/STATE/ZIP AlkttriPayike, • Nfit , 871 i 3
<br />CONTRACTOR Opal Awls leff Ild-Cer0 PHONE ?0? 793 - 3 71:7o
<br />CoNTRAcioR ADDRESS 1012-S Philadelphia Gig. CITY/STATE/ZIP goovito atakilitorlya , CA ?IVO
<br />SUBCONTRACTOR Aoore, Twa'rikib Associates, , litc_ PHONE
<br />SUBCONTRACTOR ADDRESS XS 11- FreS410 S1. , ., Crry/STATErliP FreSKII , CA 93 72,1
<br />LICENSE SIC-57 0 C-81 0 0-09 0 Other NUMBER ..1-06/ 599 EXPIRATION DATE 2/2e/2174
<br />DomEsnc WELL SANSDLING: 0 General Mineral/Conform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393)
<br />)NTENOEn USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring cyBoa Sampling/Characterization /3,41
<br />0 Public Water System
<br />If different from Owner Wider System Name Contact Name or Phone Number itE
<br />TYPE Or WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other
<br />0 Monitoring Well(s) # of wefts 0 Soil Boring(s) • °I b°6'10 ViGeotech nice I 11. • °11"t"•1 HAR /
<br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair S
<br />0 New Pump 0 Pump Replacement n Pump Repair 0 Raise Well Casing ZpAiNi.6,-/0 0
<br />rtght_Cmgingt{LIII
<br />Drilling Method 0 Mud R ry 0 Air Rotary 0 Auger D Cable Tool 0 Push Point D' Other ow 9iot At."0-ciel-,,
<br />Proposed Well Depth ft Excavation C in diameter VOpen Bottom a Gravel Pack/Gravel Size In diameter _50
<br />0 Conductor Casing In diameter / Conductor Casing Depth 11
<br />Well Casing Diameter In Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other
<br />Grout Seal Depth L-12 ft qiNeat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sad mbcf7 gal water
<br />0 Bentonite (20% solids) 0 Other
<br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name)
<br />PEDESTAL Installed By 0 Dner 0 Pump Contractor 0 Other
<br />0 Concrete Pedestal ODimenslons; Width ft Length ft Mid(
<br />in 0 Christy Box 0 Stove Pipe
<br />aitiE 0 Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level (1
<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 />NIININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASF: CALL (269)953-7697
<br />DEPARTMENT USE ONLY
<br />Application Accepted By ‘---:------. Z- Z.....-- Date 2/67 /0'.‘2 Area 1 SI 'N'-k• 6.1 Employee IOU n....---
<br />Grout Inspection By 7/171,1,--'-?7 _. LK' - 71'', -1, Date S719/ t? ' 0 SPECIAL Well Permit i
<br />Pump Inspection By Date 0 WAIVER Received
<br />Soil Boring Inspection By Date Constructed Well Depth , ft
<br />COMMENTS l'ir i'ili I i.,' 'p- -4-:,) c)(- ri , 1 (.71F er r , I- he,17 20 CP<---, k ar t r r -, --,, . .'(.44c4 ffry IS tt, .
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<br />EHD043-06 10[252021 Well I Pump Pelmet
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