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1 WELL.IPUMP PERMIT <br />JAN JOAQUIN CoUNTY ENvmormwt1TAL HEALTH DEPARTmEwr 1868 EAST HAzELTon AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS <br />56-20 AOD Crr,azip <br />CROSS STREETl%yF)YbyE�iiW <br />1+01%J <br />e��� AAPN x 61 O C1d 60 PARCEL SIZE .� LAND USE APPLICATION # <br />OVINERNAME lqky7 <br />J Z/TI%) <br />0-"r-m£fa AmAEss � CsTYiSTA-VIE . <br />CONTRACTOR <br />CONTRACTOR Arm <br />St i f3con'rRACTOR <br />SUBCONTRACTOR ADDRESS <br />LIcENSE ' C-57 VC -61 D D-09 <br />Prtone 1z) '51– Y? 7 A % y <br />CnWSTATE2IP <br />0 Other NUBTBER 1 EXPiRATm DATE <br />DOMESTIC WELL SArwUNG: D General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE /K Darrmesfir/Privale In gaticaAgriw4urai ; frx'ustrsai -- Water Ouaky Vondomg Soil Samp ing(Characterization <br />D Public Water System <br />If different from Owner. Water System Name Contad Name or Phone Number Q w <br />TYPE OF JORK _ New Well D Replacement Well L i Well Aiteration/Modifigtion -? Other <br />D Monitoring Welt(s) # of yells Soil Boring(s) # c` tsoRry' Geotechnical <br />D Out -Of ce WE41 U Out -Of -Service, Well Reneriai Cress-Coavir=cben, Repair <br />New Pump VPumv Replacement t. t Pump Repair TI Raise Well Casing <br />�af,.EIV� <br />WELL. CONSTRuc noN I" SAN <br />Drilling Method 13 laud Rotary O Air Rotary Auger ; ( Cable Tool :_? Push Point Other / ._EA <br />Proposed Well Depth ft Excavation in diameter Cl Open Bottom ' 3 Gravel Pack/Gravel Size L <br />'CMuctoirCalift in diameter / CondL torCasingDepth ft <br />Well Casing Diameter _ in Ttw*m9ss1Gaug€IASTN1 Sched Steel D Pias2c ° Stainless Steel Oar <br />Grout Seal Depth ft !_ Neat Cement (94 Ib bag15-10 gal Nater) 0 Sand Cement <br />1! Bentonite (20% solids) i; Other <br />Grout Placement Method E. Pumped D Free Fall Ci Other Retardant / Accelerator (name) <br />PEDESTAL installed By r_ Driller i= Pump Conhador <br />Concrete Pedestal +_Dimensions: VAft It Des ft Thick <br />in Christy Box Stove Pipe <br />sack mixf7 gal water I <br />MP F. Submersibles Turbine Other------,— HP Pump Set _tt Standing Water Level it <br />Plot Pian 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, dralmag a pattern, roads, existing wells, structure%, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines For Domestic, <br />A,rieulture, Industrial well, provide location of any water wells or surface nater within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By � Ly Date R 7 P a — <br />Grout Inspection By 4 1 Date <br />Pump Inspection By = Date <br />Soil Boring Irrspecfion By _ _ Date <br />COMMENTS Tin/ UMe✓1 CaaYG�) HGI }tf 6{" ►,.re 1 I. <br />l area, 'y L -- `��,p:s3 ee ;L ifliVI �< <br />SPECIAL Weil Permit <br />Ei WAivER Received <br />Constructed Vkfeli Depth <br />—Lf'T' , <br />Lk� • - //.��:'J . .. E�iiL�i�6711.iyi��'IZ'1�31�:■ <br />EID13043-06I0 2c-2021 Pzz.: I t42 ma amp P�rii <br />