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I NELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUI1i-KtFUNUAt9Lt t'tRMI I <br />GALL (ZUJ) J5.5-lbJ1 FUR INSPEGTIONS t:AI'IKtS 9 YEAR FROM LIATE ISSUED <br />JOB ADDRESS <br />ZLS)ip AtIllu lzci•/' <br />WellID# <br />CITYIZIP_M�,,� <br />CROSS STREET__ <br />Seda�t /-j�P`� <br />_ APN Qt103 <br />_PARCEL SIZE t1l LAND USE APPLICATION it <br />ONINER NAME1'1'�LS <br />_ <br />ZDI._�dq. <br />OWNER ADDRESS <br />gVQy\T <br />ZZSq V Alice LG <br />%{PHONE <br />CITYJSTATEIZIP /� a Cdl <br />CONTRACTOR <br />` <br />UILl yk 7 f)Ce W0Y1l .. Irk -C. <br />_ PHONE Zoe(. 71!s;. (DZI� <br />CONTRACTOR ADDRESS - _ISIoo • <br />S <br />T,Lt!_,tC Tr, te. 9[�_ <br />CITYISTATEIZIP A(ko-ex.. CA 953,3/r <br />SUBCONTRACTOR <br />CONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />PHONE <br />ENSE 1-1 C-57 i/ C-61 1.1 D-09 I I Other NUMBERL)L 2_7 ! (-Y EXPIRATION DATE Zig Z-2. <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />�INTENDEoUSE yDomestic/Private L' Irrigation/Agricultural Industrial Il Water Quality Monitoring Ll Soil SamplinglCharactenzalion <br />X Il Public Water System_ <br />If di ferem from OwnerWater System Name Contact Name or Phone Number <br />TYPE OF WORK "T flew Well Replacement Well 11 Well Alteration/Modification <br />I Monitoring Wells) # of wells ! 1 Soil Boring(s) <br />Tt i Out-Of-Sermce Well 1 Out -Of -Service Well Renewa <br />New Pump Pump Replacement i Pump Repair <br />F Other <br /># of borings Geotechnical <br />I- Cross -Connection Repair <br />[_ Raise Well Casino <br /># of borings . <br />JUN <br />SAN 1pq <br />Drilling Method klud Rotary L, Air Rotary i l Auger ❑ Cable Tool i Push Point I r Other L�NVih <br />Proposed Well Depth ft Excavation in diameter a Open Bottom ri Gravel Pack/Gravel Size___=_mak Nl\( <br />Conductor Casing ___ in diameter / Conductor Casing Depth _ft <br />Well Casing Diameter — in Thickness/Gauge/ASTM Sched I : Steel IJ Plastic n Stainless Steel CI Other <br />Grout Seal Depth ft 1 1 Neal Cement (94 ib bagi5-10 gal water) I I Send Cement sack mix17 gal w <br />L Bentonite (20% solids) L. Other <br />Grout Placement Method 'J Pumped 1, Free Fall 11 Other I'I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller i�,, Pump Contractor, LI Other <br />11 Concrete Pedestal IlDimensions Width t�. ft Length ft Thick rf " <br />n P Christy Box I Stove Pipe T— <br />� YNjE <br />CES 7' <br />{ PUMP jf Submersible! I Turbine Other HPPump Set_�Q_ ft Standing Water Level it <br />Not flan Requirements: Attach a plot plan with the exact location of water well With respect to the following items: CPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing Wells, strtictures, <br />potential sources of contamination, sewers or private disposal systems. Inciude distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface TYater Within 200' radius of proposed well. <br />NIINChIU.M 24 IK)UR ADVANt'F N()'I'IC'b: IttallilRf.io I.Ok !N'�Pf;(` ION,,- I'Lt..\S P: (' %IA, (2119) 05.;-;1.97 <br />% DEPARTMENT USE ONLY <br />Application Accepted By i Date v��i Areae? Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump lnspectionBy Dale`ZS SIJ���(_�ZZ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS tipW -��.t � J�;-j3 �,� ScRi^ �h� ` 1. �i.►�S� <br />STM CNTY <br />N7 <br />PE <br />Codes <br />SC Received Check#/ <br />Info as <br />Amount <br />Remitted <br />Date Permit Invoice# <br />Service Request # <br />WellID# <br />EHD(FI40o 111.15C2021 i,:,, I ,d' <br />�� � N582837� <br />W 11' Way. l'mmil <br />