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r . . i Boaz <br />1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NUN-KEFUNDABLE PERMIT GALL ZU9 953-7597 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS SSO p ?a rl 0 CnY/ZIP �(OGk{yl t <br />J (� / APN �O ( 1 �` ( o 12.oo � 4 acres & 4 acres. <br />CROSS STREET 1 l A r 041,W kN 1� of 12 oo I PARCEL SIZE LAND USE APPLICATION <br />% # <br />OWNER NAME (�, K."OLLii! �e1 AQ+ S { oC1k vn L L�. PHONE 21 1- S / 2- - �47 Z <br />OWNER ADDRESS 1W �1 We I, D j1aba- S'ti'r Assq- <br />_.CITY/STATEIZP <br />CONTRACTOR PA(UCoA LnSati#tS TLr- tX��PHONE <br />f LZL {ll/Z3- <br />3 <br />1 O ) <br />CONTRACTOR ADDRESS qo2- uSGlla1 WC+ Lj Cr"lSTATE21P GAlQ§Zqo <br />SUBCONTRACTOR NQi 7. A�cY wp 1ACPHONE-11-3— �J b t <br />SUBCONTRACTOR ADDRESS 1 o D 4 f '9 L d'Q C1/iQra! P`1 Crry/STATEMP <br />LICENSE KC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 6 6 O n ExPIRAnoN DATE <br />DOMESTIC WELL SAMPLING: Li General MineraUColiform Bacteria (4391) Dibromochloropropane (4392) U Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring )( Soil Sampling/Characterization <br />❑ Public Water System <br />K different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK i l New Well 0 Replacement Well ❑ Well AfterationlModification ❑ Other <br />l I Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Y' Geotechnical 3 # of borings <br />U Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair A <br />❑ New Pump I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION ��6 <br />Drilling Method ❑ Mud Rotary ElAir Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth_ 3'p it Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size _�'Ordjamete <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft 9 <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel 0 Plastic ❑ Stainless Steel ❑ 0 he <' <br />Grout Seal Depth 2-0 ft a( Neat Cement (94 Ib bag15-10 gal water) ❑ Sand Cement N >m <br />0 Bentonite (20% solids) 0 OtheryOFp <br />Grout Placement Method 0 Pumped V Free Fall ❑ Other ❑ Retardant / Accelerator (name) TMS. <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ODImensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level f <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L�%�- Date S �a <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS f P 1" if <br />Date <br />Date <br />Date�- <br />n/eefP✓ k oY1GcNf)' <br />Area 4i Employee ID# F(, -z ir, K <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Well Depth <br />ul <br />ERD043-06 <br />0407/2022 Page I of 2 WA / pww permit <br />w <br />MEN <br />ERD043-06 <br />0407/2022 Page I of 2 WA / pww permit <br />w <br />