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21-13` 3 ItIvar62 <br /> 1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (2091468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 25�--100 S G1 r i ssn lGt n Q d <br /> CITY/L P--T—y m <br /> � � \ p ,rte � (7 �,(� D <br /> CROSS STREET �J\) '/cy)u*C Y8 APN 2�'�C10 O 0 PARCEL SIZEISS•�LAND USE APPLICATION# �a <br /> OWNER NAME I ff b/-yy r .L..farms PHONE /�N /� �! <br /> OWNER ADDRESs SLOU P W• _121 V`�C ��• CITYISTATE/ZIP �LI l.iiR `15s7�D L O <br /> CONTRACTOR —Qc� 'V-�(Arc) )mo PHONE 2 /"1,�03L —31 tQ I <br /> CONTRACTOR ADDRESSA 1r.� v� CITY/STATE21P f)ah�0n G4 2S32C <br /> SUBCONTRACTOR IV IV9 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ;YC-57 I. C-61 :.. D-09 - Other NUMBER_IrDE11-e3 ExPIRATON DATE �I 1 0!l <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agncultural Industnal 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) aorborings Geotechnical °cC/VE 7- <br /> Out Well Out-Of-Service Well Renewal Cross-Connection Repair CC <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION S4 At J ?423 <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other O <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel R tiC7�r <br /> Conductor Casing in diameter / Conductor Casing Depth it EpgRTTq� <br /> Well Casing Diameter_LU in Thickness/Gauge/ASTM Sched •Z /Steel :. Plastic Stainless Steel Other M <br /> Grout Seal Depth ft Neat Cement(941b bagV5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _. Pumped - Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions Width ft Length It Thick <br /> lin Christy Box Stove Pipe <br /> PUMP SubmersibleX Turbine Other HP Pump Set ">t�Z 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 /> MI\1\11 NI 24 IIUI HAD\ 1S('I:\'OTICE REQUIRED FOR INSI'E(-I IONS-PLEASE CALL(209)953-7697 <br /> EPARTMENT U E ?NLy <br /> Application Accepted By Date 2 Z 3 Area s q7 Employee ID# .49 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date Zrzq WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info B Cash miffed Date Service Request# o. <br /> Invoice# Well ID# <br /> EHD043-0604,072022 Nwg 1 of 2 �1 11 Pump vermn <br /> C� <br /> � 1S7z7��9S <br />