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1 ' WELUPUMP PERMIT <br /> SAN jr AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP <br /> /A D <br /> CROSS STREET `/�'C / �t ���;� { �'> � )PARCEL SIZE S'`7 LAND USE APPLICATION#13 <br /> p <br /> OWNER NAME /f/ j PHONE <br /> i ( �+f� <br /> OWNER ADDRESS __ �`�/ / �� Dom- Vr'PS CITYISTATEIZIP l--JCR ; CA q S L/.2 y <br /> CONTRACTOR PHONE' <br /> CONTRACTOR ADDRESS �� ���/L�_�'I� r� � CrTYISTATE/ IP <br /> SUBCONTRACTOR /ri t C A J Q I l J PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE21P <br /> LICENSE D,G57 )C-61 ❑ D-09 ❑ Other NUMBER E�, ExPIRATION DATE 7? <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391) - Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Ls,Domestic/Private ❑ Irrigation/Agricultural C Industrial C Water Quality Monitoring D 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 A"Replacement Well D Well Alteration/Modification D Other <br /> _ Monitoring Well(s) #of wells D Soil Boring(s) #of borings D Geotechnical #of borings <br /> Out-Of-Service Well n Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ew Pump Pump Replacement D Pump Repair ❑ Raise Well Casing <br /> W LL CONSTRUCTION <br /> Drilling Method Mud Rotary, D Air Rotary D Auger D Cable Tool D Push Point D Other <br /> Proposed Well Depth C ft Excavation i in diameter ❑ Open Bottom iB Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft PAYMENT" <br /> Well Casing Diameter_(_ in Thickness/Gauge/ASTMSched Gs-Z` r Steel WPlastic ❑ Stainless Steel D OthKi=('EIVFD <br /> Grout Seal Depth Zw I ft .Neat Cement(94 lb bag/5-10 gal wafer) n Sand Cement sack mix/7I water <br /> D <br /> Bentonite(20%solids) Other ,EP Z <br /> Grout Placement Method &-'Pumped D Free Fall a Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller a Pump Contractor D Other <br /> Concrete Pedestal ❑Dimensions:Width i .; ft Length ft Thick <br /> in Christy Box D Stove Pipe <br /> PUMP >Submersible D Turbine D Other HP J Pump Set i'C ft Standing Water Level <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 fines, 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 /> NI.tL li 24 1100R zDA'AN€'E.N0T1 F <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 7 Date �z 2- Area f� Employee ID# . <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection ByDate ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ��I�IIr�A v,iP1 yPrt�i �+ ,Yi r(�I✓lie F,,� v71ii/C /C'aJ(i�( �N 21Dgrbv}f�Pa1 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Cas Remitted Date a Ice Request# Invoice# Well ID# <br /> 'DI Is�- 2 2 b <br /> w3-lE I 4q do 1 D` <br /> 13cl r 1 ISS J 00 )0 <br /> '-13 CJi,i <br /> 1. 3 c�3 :F7C14 <br /> T- 7 I w <br /> EHD043-0604/072022 Page I oft <br /> Well/Pwnp Permit <br />