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,s <br /> 8�15/a 3 se <br /> E�VIAIL.ED WELL/PUMP PERMIT <br /> SAN JOAQJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> EFUNDABLE(CPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �I O C C)n N <br /> V CITY/ZIP_t.i_1 1"t'- �J l:..��C m <br /> 1 �'7 1 -7 D <br /> CROSS STREET L tt''�b'"e r41 x RcV APN C.t 1C�C j G C C C` PARCEL SIZE ,�•12 LAND USE APPLICATION# 7,p cy p <br /> OWNER NAME -,J CNMt S S �.S PHONE l d 7,?-9 —/ 11tmn <br /> OWNER ADDRESS SA M Z CITYISTATEIZIP <br /> \V J 7/ <br /> CONTRACTOR x{ •e 1 0C I { ,t(�1�l _b-.HONE �}C'�) ./7�{C -,?7 /-7 <br /> 9 <br /> CONTRACTOR ADDRESS r "O CA �1 CITY/STATE/ZIP cl 1 V I C <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE AC-57 C-61 EI D-09 Other NUMBER OM 353 EXPIRATION DATE7-3 ) <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)XDibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private 'J Irrigation/Agricultural " Industrial Water Quality Monitoring -1 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 Akeration/Modification : Other <br /> Monitoring Well(s) #of wells Soil Borings) a of bonngs Geotechnical s or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUC ON <br /> JDrilling Method) Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 3346 ft Excavation 2 in diameter 1 Open Bottom XGravel Pack/Gravel Size_in diameter <br /> ConductorCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter G in Thickness/Gauge/ASTM Sched C.,-?CO _? Steel A Plastic Stainless Steel Other <br /> Grout Seal Depth i (10 ft Neat Cement(94/b bagV5-10 gal water) A Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method/(,Pumped :1 Free Fall IOther _1 Retardant/Accelerator(name) <br /> PEDESTAL Installed Byriller Pump Contractor ::I Other <br /> Concrete Pedestal Dimensions:Width� ft Length =ft Thick (12 <br /> lin Christy Box Stove Pipe <br /> PUMP Submersible ' Turbine Other HP Pump Set L 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 /> EPARTM ENT�7712,3 <br /> O LY <br /> Application Accepted By Date Area % Employee ID# <br /> Grout Inspection By Date 23 SPECIAL Well Permit <br /> Pump Inspection By WAIVER Received PAYMNT <br /> Soil Boring pIne�spection By Date Constructed Well Depth REC�l ED <br /> COMMENTS tV id wont- loo©/ 2b,2e- X, `err o � 2023 <br /> PE SC . Received Check#/ Amount Permit/ I OUNTY <br /> Codes Info B a h Remitted at Service Request# Invoice# Well I�yvttt DEPA TAt <br /> HE�AITH pEPA TMENI <br /> (o /' t3 Wt-1vo +��35 <br /> ss -- <br /> 3 2 `7 <br /> 14ID0-3.06 il•i:07:u'_ I'agt l o:2 well I Pump emmn <br />