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1 ` ' <br />WELL/PUMP PERMIT <br />MM <br />SAN JOAQium COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95M - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />.to6 ADDRESS ////q(� /J/ <br />L AA%E <br />CmfMp <br />494-1,494-1, C -IV % J�� <br />/�1-;V <br />CROSS STREET A r Ylln :� � N 1� <br />PN OS -9,330-03 <br />PARCEL SIZE 3 ; 03 LAND USE APPLICATION # <br />/ <br />OWNER NAME ���i //�!i?/I/ <br />(j i <br />(� <br />/%/J% <br />" `!� <br />P/HON�E�` O <br />OWNER ADDRESS/�O / ✓ <br />,�/'-%%/ <br />r <br />ATEPZIP <br />Cn YJST�/ <br />//�/`C�/ <br />�� g"� <br />�- (�/ L <br />/e�l/C <br />/l <br />PHONE L d - ` / <br />CONTRACTOR t�'Vj' <br />CONTRACTOR ADDRESS /) ! �/. <br />/ L(�/ <br />/ `� <br />CrrYISTATEIDP <br />sffy <br />�% <br />M/�r�A/"-'Cl t5 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ii C-57 <br />C-61 n D-09 <br />CRYIS�TA1TE21P_ <br />n Other �Z I NUMBER <br />ExPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) U Dibromochloropropane (4392) U Arsenic (4393) <br />INTENDED USE Private IrrigationlAgrickAural i industrial --Water Quality MDnitorag o Soil Sampling/Charader¢ation <br />Public Water System <br />If different from Owner: Water System Name <br />Contact Name or Phone Numte*_ <br />TYPE OF WORK �l New Well U Replacement Well U Well Akeration/Modification n Other <br />n Monitoring Well(s) # of wells G Soil Boring(s) # of borings ❑ Geotechnical VTc <br />U Out -Of -Service Well U Out -Of -Service Well Renewal 1 Cross -Correction Repair <br />❑ New Pump )<Pump Replacement U PumRRepair U Raise Well Casing rT 1 9 9y1� <br />WELLCONSTRucnoN . Qq/V /O 4UZI <br />Drilling Method C+ Mud Rotary U Air Rotary n Auger LI Cable Tool U Push Point L! Other EN q QU/ <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom U Gravel Pack/Grave v4l,- t a?ometer <br />i Conductor Casing in diameter / Conductor Casing Depth ft T MENT <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched �-- Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft U Neat Cement (94 Ib bag/5.10 gal water) U Sand Cement sack mix/7 gal water <br />G Bentonite (20% solids) U Other <br />Grout Placement Method U Pumped U Free Fall U Other U Retardant /Accelerator (name) <br />PEDESTAL Installed By - Dries U Pump Contractor c Other <br />❑ Concrete Pedestal UDhnensions Width R Length ft Thick <br />lin ❑ Christy Box ❑ Stove Pipe <br />y J T <br />IP Submersibleu Turbine U Other HP %� �J Pump Set it Standing Water Level � / ft <br />Piot Plan R uirements: 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 fines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />J—DEPARTMENT USE ONLY <br />Application Accepted By `' Date[ Area Employee ID# Frr <br />Grout Inspection By/ADate _ ❑ SPECIAL Well Permit <br />Pump Inspection By Date %"� ❑ WAIVER Received <br />Soil Boring Inspection By Date _ Constructed Well Depth It <br />COMMENTS D+u'vltnt cJdr, IYe s b well ', ��$?i31, -t,Zl.-, lJ <br />- <br />T <br />I <br />9 <br />UND043-06 M25/202I Page I of 2 we" / Pmw Pmmt <br />z <br />MM <br />a -M -�Irllill= <br />IMMUNE <br />UND043-06 M25/202I Page I of 2 we" / Pmw Pmmt <br />z <br />