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rj <br />I WELL/PUMP PERMIT 2571 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMIT GALL (ZUV) V0J-/0J/ FOR I145PECTION5 tAt'IKt.I l TEAR FROM LIArt 155UtU <br />JOB ADDRESS 9156 Connie Ave cITY121P Stockton/95209 <br />CROSS STREET Thornton RCI. APN 072-450-22 PARCEL SIZE 0.34 LAND USE APPLICATION # <br />OWNER NAME Leona Strother PHONE 209-598-4229 <br />OWNERADDRESS Same as Above CITYISTATEIZIP <br />CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY1STATEIZIP Stockton/95203 <br />SUBCONTRACTOR <br />ADDRESS <br />LICENSE I C-57 X C-61 D-09 <br />CITYISTATEIZIP <br />Other NUMBER 1055434 <br />PHONE <br />EXPIRATION DATE 7131/2023 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE X Domestic/Private ' Irrigabon/Agricuftural i ; Industrial Water Quality Monitoring ..; Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Walter System Name Contact Name or Phone Number <br />TYPE OF WORK New Well - Replacement Well G Well Alteration/Modification :. Other <br />I Monitoring Well(s) # of wells I i Soil Borings) a or bonn9s Geotechnical "01 borings <br />Out -Of -Service Well 7 Out -0f -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement . Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary -' Air Rotary i Auger Cable Tool C. Push Point I Other <br />Proposed Well Depth ft Excavation in diameter ;' Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Silted i Steel I Plastic I Stainless Steel '1 Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) is Sand Cement sack mixn gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant l Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor ❑ Other <br />Concrete Pedestal Dimensions 1Iltdth ft Length ft Thick <br />lin Christy Box Stove Pipe <br />PUMP X Submersible! i Turbine I' Other HP 1 Pump Set 70 ft Standing Water Level_ ft <br />Plot Phan Requirements: Attach a plot plan with the exact location of acuter aaell 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. ror Domestic, <br />Agriculture. Industrial well. provide location of any mater wells or surface water within 200' radius of proposed %sell. <br />\II\I\ I a1'Ir'F RI (!I WI 11 I 1 11+ t 120919'".169 - <br />DEPARTMENT USE <br />20119'3.'G9-DEPARTMENTUSE ,ONLY t <br />Application Accepted By Z�i� �L— Date 7 a r Area s t��kTu�"Employee ID# IJ <br />Grout Inspection By Date G SPECIAL Well Permit <br />Pump Inspection By Dale�Z6 ZZ E WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />In <br />In <br />D <br />a <br />M <br />m <br />m <br />CA <br />H <br />FIIn1413-06 In2512021 <br />rag. 1 or 7 <br />