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4 <br />1 WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CAL( LA 209 9+5�3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I CITYIZIP <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDI[CDJ 13 <br />AP V 1 `� PARCEL SIZE r I LAND USE PLICATION # <br />fJ� PHONE <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE )9!V.57 L C-61 C D-09 C Other <br />PHONE <br />CITYISTATE/ZIP <br />NUMBER 5'30 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE 0 Domestic/Private -_ Irrigation/Agricultural '..1 Industrial <br />= Public Water System <br />If different from Owner Water System Name <br />Water uuanry monitoring omen oainNnny v w <br />Name or Phone Number <br />n Well Alteration <br />TYPE OF WORK L New Well C Replacement Well lModiflcation ❑ Other <br />Monitoring Well(s) # Of wells ? Soil Boring(s) # of borings Geotechnical — , # of 3/� <br />Out -Of -Service Well 7- Out -Of -Service Well Renewal Cross Connection Repair "i�I `Q <br />New Pum Pum Replacement ❑ Pum Repair E. Raise Well CasingSq O <br />WELL CONSTRUCTION yFq�N�/R� UjN <br />Drilling Method Mud Rotary Air Rotary C Auger _; Cable Tool _ Push Point G Other <br />F ! <br />Proposed Well Depth ft Excavation in diameter -i Open Bottom L Gravel PacklGravel Size NI �� ter <br />c Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel D Plastic Stainless Steel Other <br />Grout Seal Depth ft -i Neat Cement (94 lb bag/510 gal water) E Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />r_..,..• oto.. —t u.thnd 1 Pumned L Free Fall `' Other C Retardant I Accelerator (name) <br />PEDESTAL Installed ey i Driller L Pump Contractor Other <br />= Concrete Pedestal IDimenslons: Width ft Lenglh ft Thick <br />in :Christy Box � Stove Pipe <br />PUMP ubmersible C Turbine :.I Other HP Pump Set! 'y 7 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 />res, <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structu <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 />�NIININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />1DEPARTMENT SE ONLY <br />Application Accepted By j-� Z Date Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />®1 <br />Pump Inspection By -4"t t;% >--`t Date FF7 1 1-L_ ZP Z Z 0 WAIVER Received <br />Soil Boring Inspection By Dat Con tructed Well Depth ft <br />,r r.' ter' lr I;FC- o ,:� cis .�P'^PS>?/c <br />COMMENTS e r <br />(' <br />r <br />PE <br />Codes <br />Sc Received Check#/ Amount Date Permitl Invoice # Well ID# <br />Info B Cash Remitted Service Niquest # <br />3F s <br />o�� h7::d <br />EHDu43-06 10,25,2021 NgI °r: <br />1Z�6Z3 <br />