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DocuSit,n Envelope ID: C620F69E-ECD2-4050-BB49-C4AB63D3E119 <br />1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT/G/�A <br />209 953-7697 FOR SPACTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />V i <br />CITY /ZIP <br />(/l <br />�` <br />CROSS STREET % <br />APN <br />/ SIZE <br />LAND USE APPLICATION # <br />/,/ <br />OWNER NAME +amu � � <br />J /�� �/��pARCEL <br />t_s 1 �t t..�t R / � <br />,r{� ^� <br />PHONE W�8 � 3 —✓3 J <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR <br />` ►/d <br />, I I V t <br />PH�O�NcY�Lyf1 L 1C1I'' I �� <br />CONTRACTOR ADDRESS P •rJ�lJ.�1� <br />CITY/STATE/ZIPI.C/�� <br />�PHONE <br />SUBCONTRACTOR <br />vy <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSEC-57 C C-61 D-09 <br />P Other <br />NUMBE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 1 Arsenic (4393) <br />NTENDED USE Fi Domestic/Private XIrrigation/Agricultural Industrial --i Water Quality Monitoring ["I Soil Sampling/Characterization <br />[,l Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ^New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells 7 Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well 0 Out -Of -Service Well Renewal Cross -Connection Repair <br />INew rump rump Replacement rump Kepair Raise Well Gasing <br />WELL CONSTRUCTION <br />Drilling Method Mud R Air Rotary , Auger ^ Cable Tool Push Point I Other <br />Proposed Well el ft Excavation 14 in diameter Open Bottom )(Gravel Pack/Gravel Size in diameter <br />Conduct wCasing in diameter / Co ctor Casing Depth / ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sche_ Steel XPlastic Stainless Steel i Other <br />Grout Seal Depth _ ft I Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />entonite (20% solids) I Other <br />Grout Placeme t Method Xumped i Free Fall Other Retardant / Accelerator (name) <br />)EDESTAL Installed By Driller Pump Contractor Other <br />J Concrete Pedestal ]Dimensions: Width ft Length ft Thick <br />:1 Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible:- Turbine Other HP Pump Set ft Standing Water Level 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 />NUNibtt M Z4 1100C AD: :kN(E N B I1( dtEQ IRLD I OR INSilEC; l'1 Des - PLI.riSE CALL 120) 937 ,69'; <br />DEPARTMENT USr N L Y <br />Application Accepted Bye Date ZZ <br />Grout Inspection By �-.; .ir r s; : C. ros:,; i Date <br />Pump Inspection By Date <br />Soil Boring InspepAion By Date <br />COMMENTS /V a, 1;" Ao it" til Ed �%/�� _t) bt1c re -,r <br />Area �PgyE <br />E SPECIAL Well Pe EIVVED <br />E WAIVER ReC1lIARkd n _ <br />PE SC Received / Amount Permit/ <br />Ch <br />Codes Info B C sh Remitted Date Service Request # Invoice # 1�1D# <br />�w •� 2t wPo <br />EHD(W3-06 10/25/2021 Page I of 2 Well / PunV Permit <br />T <br />m <br />D <br />a <br />X <br />chy <br />CZ <br />