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I <br />`- )a 19J WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT C01 1 19111141 092_71t07 mono rvnfere. A - _ ___ <br />-- -- nlvvvvwIwwv GAr'lF%=Q I TtAKI-KUM IJAIE ISSUED <br />JOB ADDRESS 10 C FIONA CITY/zIP <br />CROSS STREET rtA N O S PARCEL SIZE 5 LAND USE APPLICATION # <br />OWNER NAME 1 PHONF�- q1 d 133 <br />OWNER ADDRESS 1 CITYISTATElZIPr.4 Q <br />CONTRACTOR 11 I '�/J✓�rn�� _"�� <br />PHON <br />CONTRACTOR ADDRESS 10,1 a i On CITY/STATE21P <br />SUBCONTRACTOR PHONE <br />SUBCONTRACT RADDRESS /STATE/ZIP <br />\- <br />LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE a "r <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private F] Inigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />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 ❑ Soil Boring(s)# of o <br />borings _Geotechnical <br />- Out -Of -Service ell Out -Of -Service Well Renewal ❑ Cross -Connection Repair c CQ <br />WELL CNS <br />New Pum Pum Replacement Pum Repair ❑ Raise Well Casin `SCP <br />OTRUCTION N JD <br />2_27 <br />Drilling Method C Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Push Point ❑ Other N FNS/ Q�// <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sizei�ftzpter <br />I Conductor Casing in diameter / Conductor Casing Depth ft T� I <br />EN <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ,Steel El Plastic ❑Stainless Steel 13 Other i <br />Grout Seal Depth_ft <br />ft ❑ Neat Cement (94 Ib bag/5-10 gal water) E Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method c Pumped -� Free Fall ❑ Other F Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal `1 Dimensions: Width It Length ft Thick <br />in - Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine ❑ Other HP_L 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 />it _ :'; ', 'iv : -NS - PL AS3:, C: _ 309)953-76911 <br />DEPARTMENT USE ONLY <br />Application Accepted By �' �C Date�� �.+�« <br />Area -7 � % Employee ID# rC <br />fe7 ►'Ik <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By ! - I Date I TO WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS (_ %►'/r 1'l �� /nog f'S W%/(- <br />it <br />1,2 S() <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B Cash Remitted Date Service Request # Invoice # Well ID# <br />L13Ni o Ste- 4-77 A19,(� <br />43- 6 04/07r2022 �I Page 1 ort <br />Well / Pum Permit <br />r� <br />D <br />0 <br />v <br />m <br />y <br />N <br />