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I WELUPUMP PERMIT <br />AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERGMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � C ay- a �y lCITY/ZIP �c1h95pZ/ <br />CROSS STREET�e�}� wQn� �"11/� ApN YidOd d PARCEL SIZE 1 S <br />r '�y LAND USE APPLICATION # <br />OWNER NAME ►"larC U"n PHONE aoq- <br />OWNER ADDRESS ����������� CITY/STATE2IP222 CITY/STATE21P a� <br />CONTRACTOR C)y_Maxi PHONE [ Def - q3 <br />CONTRACTOR ADDRESS I� I Ai>r CI Y/STATE21PS-f o Ck m c* qs�� I S' <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 9,C-57 D C-61 <br />DOMESTIC WELL SAMPLING: <br />PHONE <br />CFTY/STATE21P <br />D-09 ❑Other NUMBER - [ l & EXPIRATION DATE .31 /a 3 <br />General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE XDomestic/Private Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring a Soil Sampling/Characterization <br />E Publi W t <br />c a er System <br />If different from Owner: Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK -; New Well _ Replacement Well r5 Well Alteration/Modification <br />a Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings ❑ Geotechnical 9 of borings <br />- Out -Of -Service Well Out -Of -Service Well Renewal <br />❑ Cross -Connection Repair <br />New PuM2 j4. Pump Re lacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />- Raise Well Casin <br />Drilling Method = Mud Rotary ❑ Air Rotary ❑ Auger Fi Cable Tool Push Point <br />❑ Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in <br />diameter / Conductor Casing Depth <br />ft <br />Well Casing Diameter _ in ThicknesstGauge/ASTM Sched Steel <br />Grout Seal Depth <br />❑ Plastic Stainless Steel ❑Other <br />ft � Neat Cement (94 Ib bagl5.10 gal water) <br />Sand Cement <br />- Bentonite (20% solids) Ej Other <br />sack mix/7 gal water <br />Grout Placement Method _ Pumped , Free Fall =i Other -: Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor _ Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in Christy Box ❑ Stove PiDe <br />It—UMP 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 />MININIUNI 24 IIOCRAD\ ANCL \01'IC'L RE, QCIRLD FOR INSPE(.TIONS- PLEASE CALL, (209) 953-7697 <br />Application Accepted By�� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By _ <br />COMMENTS L)Qc � rll <br />DEPARTMENT USE ONLY <br />Date Area <br />Employee ID# <br />Date ❑ SPECIAL Well Permit <br />Date C IJ WAIVER Received <br />_ Date <br />Constructed Well Depth <br />PE SC Received hec Amount PerrniU <br />odes Info B ash Remitted Date Service Request # <br />3e l HIff YO 14-72 ZJ NCOOLIStaf, <br />Invoice # <br />E14DO43-06 04/07/2022 <br />Page I oft <br />Well / Pump Permit <br />ft <br />rp <br />D <br />0 <br />X° <br />M <br />rn <br />