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Zi-0 Jo it-- 00 "7CR9 WELUPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 NON-REFUNDABLE PERMIT 1 CALL y209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Lo JOB ADDRESS I St c-,l ko„rr. )3 CX CrrY1ZIP `�ra.c.J C1.�3 J b m �} n ^ D CROSS STREET AO C"l'r ROI r/ 3f3)APN d�[Sn[.)�1 V —Qg7 PARCEL SIZE OC):k. LAND USE APPLICATION# A OWNER NAME AW ow I1nt-A C�rL�,t rSs Lf PHONE OWNER ADDRESS Q S 13 /4-.%0,,J 4,r4. CRYTATEIP /S /Z tT x} \ CONTRACTOR _g,c��i'Oro, Bros C1r�1,•'�t; `y�L. PHONE =/ 31 7��— I J3 Q y� i 1 `!],, ! � -7.5,97,6 JL CONTRACTOR ADDRESS SIS I` q-,er� M& . CfTY�STATE/ZIP Pa Tal✓ qA I e.o t...A /.5,9/N i SUBCONTRACTOR I PHONE SUBCONTRACTOR ADDRESS Crrry/STATE/ZIP UVEWSE V101 N/ ;--Vt 4iirn ^Jhrw T_-)ttvr<ura -z-m 3U o73 DOMESTIC WELL SAMPLING:❑General MinerallColiform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE Domesbc/Private IrrigatienlggriCUltural Industrial Water Quality Monitoring Soil SamplinglCharacterization PAY Public Water System '`1 ]' EN If different from Owner: Water System Name Contact Name or Phone Number I 1 ,� TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other /� V D Monitoring Wetl(s) #of wells Soil Boring(s) 9 of bonngs Geotechnical "or bon 1, 3 2021 Old C1f�SenricP Well cu-"-sar)rit-J.Wa RFWUe5&01 [jrL s-Cnnnft-ixnn Repair New Pum Pum Replacement Pum Repair Raise Well Casing SAN SOA WELL CONSTRUCTION HEATH v'NCNP, NTA Ty Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other DEpq TMENT Proposed Well Depth ft Excavation 2�p in diameter Open Bott m Gravel Pack/Gravel Size in diameter Conductor Casing�_in diameter / Conductor Casing Depth ft Well Casing Diameter t�R in Thickness/Gauge/ASTM Sched 1 3iZ Steel Plastic Stainless Steel Other Grout Seal Depth 15 D ft Neat Cement(94 Ib ba96-10 gal water) Sand Cement 110. 3 sack mall gal water Bentonite %s ds) Other Grout Placement MethodPumpe Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions:Width ft Length ft Thick �in Christy Box Stove Pipe PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines. adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures. potential sources of contamination.sewers or private disposal systems_ include distance from two property tines.For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. X11\I\iL Nl 24 HUL 11:-I)%.%NCE�0l ICI:la:Ql IKF.D PUIi INm'Ix I loNs-i'L.E.»E C.CLL.k2119)953-769' DEPARTMENT USE ONLY Application Accepted By �_�L L Date 112 ae d Area__5/ Ci Employee ID# Grout Inspection By ) ) C/ �� Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAMR Received Soil Boring Inspection By Date Constructed Well Depth tt COMMENTS t f:AtE pLl !SIT hec't7rrC PI/"yIC 1/SZUcLjJr- 1Z� �•EfoC:;��trlf vJf Jl /nGrC4i;1c, fs. PE Sc Received Chec Amount ate Permit/ Invoice# Well ID# Codes Info ash Remitted Service Re uest# �136q I FO Z $9 rnna-Lnr,III 2c2o21 ry.I.,r2 atu r."y,r—un i