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� �-i3`t3 I�tvc�r�2 <br /> 1 WELUPUMP PERMIT <br /> SAN JOAQUIN 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 25u0(� S Ch r sit i n Qd T m <br /> CITY/LP I <br /> �(� D <br /> CROSS STREET VL) C► t L. C-F Y APN 2� 1_In Q_ O )0 PARCEL SIZESS-1-C LAND USE APPLICATION# <br /> rn <br /> OWNER NAME Q�tVGlY2Z Ar PHONE y <br /> OWNER ADDRESS U�IJI D L��y1�� ' CITY/STATEIZIP `� �1�^� J^���1..(( <br /> CONTRACTOR.Dan ` d�ro R mQ I�PHO/NEu(l e)Ula —31 t Q I <br /> CONTRACTOR ADDRESS f.l�A '���pin rS CITY/STATE/ZIP fI l 4 ).1DI� Vf7 9��(� <br /> SUBCONTRACTOR N` 9 PHONE <br /> SUBCONTRACTOR ADDRESS 1 CITY/STATE/ZIP ` <br /> LICENSE )(C-57 ❑ C-61 D-09 Other NUMBER- -rZ9 U3 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial is 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) #of borings Geotechnical f C 7' <br /> Out-Of-Service Well Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pump Pump Replacement �i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -] Mud Rotary Air Rotary C' Auger _ Cable Tool Push Point - Other S4 IV JC O�� <br /> Proposed Well Depth It Excavation in diameter Open Bottom - Gravel Pack/Gravel R ter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth It 0-6-`AIR <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched 'z� Steel :_ Plastic Stainless Steel Other h1 <br /> Grout Seal Depth ft Neat Cement(94 Ib bag15-10 gal water! Sand Cement sack mix17 gal water <br /> =i Bentonite(20%solids) : Other <br /> Grout Placement Method : Pumped Free Fall : Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By E Driller Pump Contractor Other <br /> Concrete Pedestal 1-,DimensionsWidth it Length ft Thick <br /> lin Christy Box Stove Pipe <br /> PUMP Submersible Turbine L: Other HP Pump SetAA.- 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 /> N11\'IVt\t 24 1101'R.aUk:%\('E.\OTICE REOUIRED FOR 1\SPEX-1IO\S-PLEASE:CAL1.(209)953-7697 <br /> EPARTMENT U E OINLY <br /> Application Accepted By Date 2 (4* I Z J Area 99' Employee ID# 149 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date_Z,� Z�( WAIVER Received <br /> Soil Boring Inspection By Date I Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info By, Cash miffed Date Service Re uest# Invoice# Well ID# <br /> 0 0 / _57 J/ot DO Z <br /> Etm043-06 04/072032 I of? Well Pump Perrmt <br /> (low ///Ij/•Irr- 1s7z7��9S <br />