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1 WELUPUMP PERMIT <br />SAN JoAau N COUNTY ENVRtoNMEN'TAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209! 468-3420 <br />NON-REFUNDABL-E PERwr CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoBADDREss ZD -? --/ 4PEII) •���,f �} CrTYIZrP �i C� �� G <br />CROSS STREET Az+ k lid - �7 p n / J� APN ©l '"1 3 � 0 0 7 PARCEL SIZE L I' -7LAND USE APPLIGCAnoN # q <br />OWNER NAME L z ) );V �(- (/ �J�9y� PF�NE �U / 712-- 3 / 4 <br />OWNER ADDRESS CmISTAEZ'2 <br />CONTRACTOR <br />CONTRACTOR dt%Lf �-z Vle/PHONE <br />CONTRACTOR ADRESS `" CnYISTATE2P //L <br />SUBCONTRACTOR � <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY1STATCE0r <br />LICENSE I i C-57 C$1 D D409 Other �Z� NUMBER o EXPIRATION DATE 3 <br />DoMEsTlc WELL SAMPLING: ❑ General Wheral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE F� Domestic/Private 7 IrrigationfAgricuttkral U Industrial Water Quality Monitoring t s Soil Sampliing/Charaderrzation <br />U Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well 'Replacement Well U Well Alteration/Modification C Other <br />U Monitoring Well(s) # of wells U Soil Boring(s) # of borings D Geotechnical # I l C <br />1. —. — c_____ %Ar..rr n rl.d_(!F Cnnivn yu-m R--m::tl - rrnnr- AfY1PL . tr rn-_ CO <br />Cad <br />Well <br />11 <br />WELL CONSTRUCTION i� <br />Drilling Method U Mud Rotary Ii Air Rotary D Auger U Cable Tool -1 Push Point C; Other hE44 /RO /N C <br />Proposed Well Depth ft Excavation in diameter U Open Bottom ; 0 Gravel PaddGravel Size p4/'y7" tr► iometer <br />Conductor Casing in diameter / Conductor Casing Depth ft FNT <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel U Plastic ;1 Stainless Steel U Other <br />Grout Seal Depth ft U Neat Cement (94 Ib bag(5-10 gal water) 17 Sand Cement sack mixl7 gal water <br />C! Bentonite (2D% solids) U Other <br />Grout Placement Method U Pumped U Free Fall U Other U Retardant /Accelerator (name) <br />fDESTAL Installed By U Driller U Pump Contractor Offw <br />t7 Concrete Pedestal [-,Df pensions: Width ft Length ft Thick <br />U Christy Box U Stove Pipe <br />PUMP �4Submersibles Turbine 1_7 Other HP Pump Set / U it Standing Water Level f/ '� ft <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 Hues. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By 1-� �� L Date Nf Z Area r f Employee ID#_ <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By J-(-kfn4 , L� i� , Zkf-_ Date ` q� -7 1 D WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS D n t V n'i't (?yl r,,-',Ofd <br />[.� o f d <br />Date <br />Constructed Well Depth <br />ft <br />LA <br />m <br />to <br />R <br />E11Ix043-06 10;25/2021 Page I ort Well l ParW Pemut <br />