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tl �s 22 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA952b5 -(209)4693420 <br /> NON-REFUNDABLE P7ERIMff CALL 209 IO <br /> 953-7697 FOR INSPECTNS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 Z CnvfZm ✓-3 k r� <br /> D <br /> CROSS STREET �\ `I QA//PN 2-W-220-00() PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME 1'v �1 �' �"`� ,*�/ { f " m <br /> 1�y�p� �AmtJv/ PHONE <br /> OWNER ADDRESSy i kI{i LO 1 O V 1 1 Y(V� CnYJSTATE/2yP <br /> CONTRACTOR <br /> 1111 dY1�11 V PHONE <br /> CONTRACTOR ADDRESS 11q �l ,� . Cn~/STA,EIZlP'M.OII,P,Sid L A aP�1 <br /> SUBCONTRACTOR PHONE <br /> SUBComTRACTOR ADDRESS CITYISTATEMP <br /> LICENSE GSI ❑ C-61 ❑ D-09 ❑ OINef Nunn EXPwmmm DATE • <br /> DONES71C WELL SAYPL]ING:D General Mineral/Coliforim Bacteria(439 1)a Dibromachloropropane(4392),-]Arsenic(4393) <br /> INTENIM USE rivate ❑ IffodioiVAgricurt,ral ❑ Industrial ❑water Quality Monitoring ❑ Sal SamplingfLZoractm; atiOnnP <br /> Public water system - N <br /> If ciftled iron Owner: Wer System Name Conlad Name or Phone Number1" <br /> TYPE OF WORK ew Well C Replacement Well ❑ Well AlterationlModification ❑ Other D <br /> U Monitoring Well(s) #of wells ❑ Soil Boring(s) '"bon"gs ❑Geotechnical <br /> 11A of / <br /> Out-Of-Service Well ❑ Out-MS11S <br /> ervice Well Renewal Cross-Connection Repair 7 2022 <br /> U New Pump Replacement ❑ Pum R it ❑ Raise Well Casing .Jp <br /> WELL CONSTRUCTION Hls STH p NI�EN� NTy <br /> Drilling MethodtMudR I ❑ Air Rotary r]Auger LI Cable Tool ❑ Push Point ❑ O r EF' Nr <br /> Proposed Well thft Excavation —in diameter ❑ Open Bottom Gravel Pack/Gravel Siz meter <br /> in dia <br /> ❑ Conduct Casing in diameter I Cond nt ng Depth ft <br /> Well Casing Diameter in Thidmess/Gauge/ASTM Sched " <br /> Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal r ft ❑ Neat Cement(94 lb bagr5-10 gal water Sand Cement sack mW7 gal water <br /> )rBe,nhoqft- <br /> (20%solids) D Other <br /> Grout Planatrne A Method Pumped ❑ Free Fall ❑ Other n Retardant I Accelerator(name) <br /> P113*4TAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin U Christy Box ❑ stove Pipe <br /> PM ❑ Submersible❑Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> Plot Plan Requirements: Attack 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT US [�O LY lip <br /> Application Accepted By Date ` 2Z Area -r / Employee ID# _ <br /> Grout Inspection By �i i Date �' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Sod Boring Inspectiorl By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received CheddW Amount Dab Peri Invoke* Well ID# <br /> Codes Info Remitted Servke Request <br /> /-o ZZ <br /> EHDoas-ab owrrmn PW i of 2 Well i wIM Permit <br />