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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 JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE )(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER CrTYISTATEIZIP EXPIRATION 0 DOMESTIC WELL SAMPLING: i GeneraLl Mineral/Coliform Bacteria (4391) F. Dibromochloropropane (4392) L Arsenic (4393) INTENDED USE ❑ Domestic(Private Irrigation/Agricultural EJIndustrial ElWater Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System /"^I K different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK I�New Well ❑ Replacement Well ❑ Well Afteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # °r borin� ❑ Geotechnical °f bOf"9$ AR 0 ❑ Out -Of -Service Well ❑ Out-OfService Well Renewal ❑ Cross -Connection Repair SAN J ❑ New Pump 11 Puma Replacement [I Pump Repair ❑ Raise Well Casing �A4Ul� WELL CONSTRUCTION "1 LTH AFP Drilling MethodIpth Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point 11Other A Proposed Well 4S'O ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched �0 ElSteel TPIastic LlStainless Steel D Other Grout Seal Depth oft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite (20% solids) ❑ Other Grout Placemen ethod YPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set It Standing Water Level it Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS 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. NINIMUN 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Application Accepted By DEPARTMENT USE ONLY Date --�7/ "� Grout Inspection By^Date / I / % z2. Pump Inspection By Date Soil Boring Inspection By COMMENTS Date Area 7 Employee ID# F r" ❑ SPECIAL Well Permit ❑ WArvER Received Constructed WeN Depth C' �J-- R PE SC Received Codes Info B CALL 209 953-7697 FOR INSPECTIONS LA'IKt* 7 TEAR FROM WAIF I,SUEU 1.l3'�e3 a CITYIZIP Cltffl l " s' G& q � APN I O - .,/ V O PARCEL SIZE JGINO USE APPLICATION # PHONE �( Z /} CI Y/STATE/ZJP C��xt S A j',�'% ; J L7 -Z-7 V DTI 7a IIIhU 1 nG PHONE - 1 71Irs �jj2,-1 1 G,� CITY/STATE/ZIP "1 7�r2 v ✓ " PHONE_ LICENSE )(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER CrTYISTATEIZIP EXPIRATION 0 DOMESTIC WELL SAMPLING: i GeneraLl Mineral/Coliform Bacteria (4391) F. Dibromochloropropane (4392) L Arsenic (4393) INTENDED USE ❑ Domestic(Private Irrigation/Agricultural EJIndustrial ElWater Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System /"^I K different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK I�New Well ❑ Replacement Well ❑ Well Afteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # °r borin� ❑ Geotechnical °f bOf"9$ AR 0 ❑ Out -Of -Service Well ❑ Out-OfService Well Renewal ❑ Cross -Connection Repair SAN J ❑ New Pump 11 Puma Replacement [I Pump Repair ❑ Raise Well Casing �A4Ul� WELL CONSTRUCTION "1 LTH AFP Drilling MethodIpth Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point 11Other A Proposed Well 4S'O ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched �0 ElSteel TPIastic LlStainless Steel D Other Grout Seal Depth oft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite (20% solids) ❑ Other Grout Placemen ethod YPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set It Standing Water Level it Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS 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. NINIMUN 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Application Accepted By DEPARTMENT USE ONLY Date --�7/ "� Grout Inspection By^Date / I / % z2. Pump Inspection By Date Soil Boring Inspection By COMMENTS Date Area 7 Employee ID# F r" ❑ SPECIAL Well Permit ❑ WArvER Received Constructed WeN Depth C' �J-- R PE SC Received Codes Info B Check#/ Cash Amount DOe Permit/ Invoice # Well ID# Remitted Service Request# 1.l3'�e3 a sem- o z 1,. GHD043-06 1625/2021 nd -1.3161-7 28.7 Page I of 2 W0 / Pump Paulin