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EMAILED 1 <br /> • � �m` 9 aoa 3sa <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIST, CALL(2,Q9) 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADORES t/ CITY/ZIP — i 1 '� ' m <br /> �]f� 0 D <br /> CROSS STREET AP / r I PARCEL SIZE r�� I LAND USE APPLICATION# o <br /> PHONE _ t m <br /> .1(} /6n ur <br /> OWNER NAME _)Q <br /> OWNER ADDRESS 1 / CITY/STATE/ZIP /� <br /> CONTRACTOR G / PHON / -�(�f <br /> CONTRACTOR ADDRES ' 1' CITY/STATE/ZIP ^l 44, 151JL J <br /> SUBCONTRACTOR ��jj7���nn PHONE <br /> SUBCONTRAC OR ADDRESS�l CL� (_( �/a� J� Crry/STATE/ZIP <br /> LICENSE C-57 11 C-61 ❑ D-09 C Other NUMBER 41OW&I EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE L Domestic/Private _ rrigation/Agricultural Iiindustrial CI Water Quality Monitoring L Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number 17 <br /> - <br /> TYPE OF WORK New Well Replacement Well C Well Alteration/Modification ❑ Other <br /> L Monitoring Well(s) #of wells L Soil Borings) #of borings CI Geotechnical #�T�Cgrjngs <br /> 1 p <br /> C Out-Of-Service Well F Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum C Pum Replacement L Pum Repair 11 Raise Well CasingSqNPA, 04(-)',,-13 20?3 <br /> WELL CONSTRUCTION FgLT ON C0 U <br /> Drilling Method �Mud Rotary i Air Rotary i i Auger ❑ Cable Tool 1 Push Point H Other N CEpgENTq N <br /> Proposed Well Depth L. ft Excavation in diameter U Open Bottom )r^Gravel Pack/Gravel Sizef, r in dia <br /> it Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter f L�, in Thickness/Gauge/ASTM Sched C� 4.0 ❑ Steel Plastic CI Stainless Steel i I Other <br /> Grout Seal Depth ft L Neat Cement(94 Ib bag/5-10 gal water) 1-1 Sand Cement sack mix/7 gal water <br /> "entonite(20%solids) i Other <br /> Grout Placemen Method Pumped r Free Fall L Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By fi Driller Bump Contractor I I Other <br /> I_ Concrete Pedestal I:!Dimensions:Width ft Length K—ft Thick <br /> in Christy Box L Stove Pipe <br /> PUMP Submersible[] Turbine F Other HP ! Pump Set__L!{ ft Standing Water Level 3C- 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 /> ILLNLaiU."i 24 HOUR ADN AiNCi-, iCE RE(,I 0 FOR iNSPEC'1iONS-PLEASE CALL k209)9-5j-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area i` Employee ID#t�_ <br /> Grout Inspection By Date Z 7 SPECIAL Well Permit <br /> Pump Inspection By Date __1 WAIVER Received <br /> Soil Borine' .,r 'ion By _ Date, Constructed Well Depth ft <br /> COMMENTS 1���4– AT <br /> T <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> -a WP001-4-550 <br /> l 15-6-C69-13-03 <br /> EHU043-96 IW/117,2022 Page 1 oft WA/Pump Pcmiit <br />