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I WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL ZUy yb3-lbtti FOR INSPECTIUNS c.ArlKea I i EAK I'KU^�M UAI t I,JUCU 1 0 JOB ADDRESS tt// J C^ / E IVI 't 11'� Irk y p _ CITYILP �C c i I) 1"U i G) �� J C! CROSS STREET K'eRYlyt • rC Q7. AP V-� ��0 6 PARCEL SIZE '' L'' LAND USE APPLICATION OWNER NAME IJ C, n a I! Q'n YAC I G•t / PHONE q 1 ,�� — 7 1 OWNER ADDRESS iL', M11C' j\ ____ CITY15TATEILP ,�`\ t-�'''�L! A GI 5 , 11 -20 CONTRACTOR9 // PHONE Jy'' C1 r j-7 7 9 CONTRACTOR ADDRESS (' 13 L' CITY/STATE/ZIP `-' L, , �� _ i) G7 .i SUBCONTRACTOR ADDRESS CITY/STATE/ZIP PHONE ��77C �� .�' EXPIRATION DATE 7-3 C-57 L 0-61 ❑ 0-09 U Other NUMBER :J( DOMESTIC WELL SAMPUNG: ji General Mineral/Coliform Bacteria (4391)(Dibromochloropropane (4392) D Arsenic (4393) INTENDED USE A DomestictPrivate P Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization O Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK Y New Well .� Replacement Well ❑ Well Alteration/Modification Ll Other 0 Monitoring Well(s) # of wells D Soil Boring(s) *of bonngs L1 Geotechnical a of bo Ings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New PumD C Pumo Reolacement Ii Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method fk Mud Rotary p Air Rotary a Auger J Cable Tool Ll Push Point G Other Proposed Well Depth ft Excavation _ in diameter u Open Bottom %,� Gravel PacklGravel Size 1/4 in diameter Conductor � Casing in diameter I Conductor Casing Depth ft Well Casing Diameter �_ in Thickness/Gauge/ASTM Sched _C I 7L L ❑ Steel KPiastic ❑ Stainless Steel D Other Grout Seal Dept ft ❑ Neat Cement (94 Ib bagl5-10 gal water) SPS Sand Cement._ 1c),5 sack mW7 gal water FI Bentonite (2U% solids) G' Other Grout Placement Method A Pumped ❑ Free Fall ❑ Other F Retardant /Accelerator (name) PEDESTAL Installed By X Driller D Pump Contractor71 Other Concrete Pedestal ❑DWidth dth 3 ft Length _ _ It Thick III lin 7 Christy Box ❑ Stove Pipe PUMP ;_; SubmersibleC 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: CPS 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. /l DEPARTMENT USE ONLY Application Accepted By / Date ,r' % Area t _ Employee ID#FR Grout Inspection ByyiSLc (L7KrEa r�(" 2- Date I j 112-2-- ❑ SPECIAL Well Permit Purnp Inspection By Date _ ❑ WAIVER Received Soil Boring Inspection By Date Constru T Well Depth ft COMMENTS GXlsif�! :' �.1 @-i►1L Irk>� 11 FC C4 S w�1 ElID043{610/25!2021 Page I of t ��`/3�283239 Eq�TyO°pqmv�0 TMFNr ff= WOMMA��EMHOM . ElID043{610/25!2021 Page I of t ��`/3�283239 Eq�TyO°pqmv�0 TMFNr