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1 WELL HERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVFNIIF . STM-kYrNu Ce 04101a ronin wee e.we <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM 'DATE ISSUED <br />JOB ADDRESS I �d_ 6 6 L d(,t /�' C C/ y CtrY/ZIP�CA�D <br />CROSS STREET (, 5e- APN 190507001 PARCEL SIZE d o LAND USE APPLICATION # <br />OWNER NAME t # I �G '��w% 1 (� PHONE _ <br />OWNER ADDRESS r, - ` /t �Q _ CITYI$TATE/ZIP <br />CONTRACTOR <br />n _ ._-- PHONE <br />CONTRACTOR ADDRESS a�S 49!r--- CITY/STATE(ZIP_G- <br />SUBCONTRACTOR PHONE. <br />SUBCONTRACTOORL. <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP___ <br />ll C-_ <br />LICENSE 57 L C-81 D-09 /,!!2_) • Other _ NUMBER EXPIRATION DATE <br />UUMr=STIG VVELL,AMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Pdvate i Irrigation/Agricultural Industrial Water Quality Monitoring I Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number A <br />TYPE OF WORK C New Well C Replacement Well Well Alteration/Modification F Other <br />Monitoring Wells) # of wells Soil Boring(s) # of bcrings Geotechnical <br />E Iut-Of-Service Well Out -Of -Service Well Renewal Cross• Connection Repair <br />New Pump I Pump Replacement Pump Repair Raise Well Casino <br /># of borings <br />✓/N 2 <br />Drilling Method I Mud Rotary I Air Rotary Auger Cable Tool ! Push Point Other r7EA, V 14 �r <br />Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in dia 4-1 <br />Conductor Casing in diameter ! Conductor Casing Depth _ R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel I Other <br />Grout Seal Depth ft Neat Cement (94 /b bags& 10 gal water) Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) :1 Other <br />Grout Placement Method ! Pumped I Free Fall ! Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller I Pump Contractor i Other <br />I Concrete Pedestal iDimensions: Width ft Length ft Thick <br />in I Christy Box i Stove Pipe <br />PUMP Vf ubmersible! Turbine Other HP -5_ Pump Set ft Standing Water Leve PDk-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 lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />\11\1NII 1i 2111W It X111 INCL \01 I( E I(FQt'IRED FOR INSPE(' IONS -PLEASE ( \IA (2119(913 -?h97 <br />9 DEPARTMENT US£ ONLY <br />Application Accepted By /,� Date _ Area qlqq <br />Employee ID# A& <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By ate ZZ„1 VAS' -L%.-022 WAIVER Received <br />Soil Boring Inspection By Date I <br />COMMENTS JeVJ wWel Aef` %I WP 00d$'Na 4 3611 3 <br />'A Q 0 ago <br />Constructed Well Depth <br />ft <br />4' <br />M3043-06 W%07,2023 Ng" 1.[ 2 Wen ' Ponv Pxmn <br />IfZJ '10 H 163733 <br />Service Request # <br />M3043-06 W%07,2023 Ng" 1.[ 2 Wen ' Ponv Pxmn <br />IfZJ '10 H 163733 <br />