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i WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)46"20 <br /> NON-REFUNDABLE PERMIT �Q CAL 209 953-769.7_ FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED y <br /> JOB ADDRESS �Y 1 GiTYIZIP oG I� n q - m <br /> w - <br /> 0 <br /> CROSS STREET NW APN O- O D PARCEL S¢E 3-7 LAND USE APPLICATION# � <br /> - Zoe. M'9- <br /> OWNER NAME PHONE <br /> OWNER ADDRESS Y)Yi Z 1 " I CITYISTATE/Z1P s�)M N r 0\ 01 i2 <br /> CONTRACTOR m I s DNI n r)V fP1H/O�NEE� ����j� aq��f0�j <br /> CONTRACTOR ADDRESS I CtTYISTATE/ZIPIrlV�+"�M, V- I9- " 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/ST'A(�T'EMP �} <br /> LICENSE C-57 1-1C-61 i:I D-09 fl Other NUMBER `+� ExPmAnON DATE 1 �•�� <br /> DOMESTIC WELL SAMPLING:X General MinerallColiform Bacteria(4391)•< Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE mestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charact <br /> 1 <br /> 7 Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE Of WORK New Well F1 Replacement Weil ❑ Well AlterationfModification ❑ Other <br /> ❑ Monitoring Well(s) #of wells C Soil Boring(s) #ofborings [l Geotechnical <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAID 1/04 QLf <br /> ��2? <br /> t-] New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casng EN r- <br /> WELL CONSTRUCTION TH DEP 61V NT <br /> Drilling MethodMud Rota ❑ Air.Rotary ❑ Auger ❑ Cable Tool ElPush Point U Other ART <br /> Proposed Well tpth _ft Excavation 01II in diameter ❑ Open Bottom �Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct Casing in diameter I Conductor Casing Depth ft - <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched (i Steel n Plastic G Stainless Steel ❑ Other <br /> Grout Seal Depth ft it Neat Cement(94 tb bag/5-10 gal water) Sand Cement 10.3 sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller CI Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �jn L' Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersiblef i Turbine ❑ Other HP Pump Set it 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 /> NI NINIUNI 24 HOUR ADVANCE NOTICE REQUIRED I-OR IV'SPE('770NS-PLEASE CALL(21191953-7697, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ � Date.- �/�_' '�� Area �` ���: Employee ID# <br /> Grout Inspection By Hyl Date 21-k.N—N Zo i z 11 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constricted Well Depth ft <br /> COMMENTS I• 1': ! c'1 G75�.i'. / rC �{; �✓ r",. .r-�o ( it'<.+ ' ,`t'i { may( +� <br /> PE SC Received Check#/ Amount D Permit/ Invoice# Well ID# <br /> Codes Info Alin Cash Remitted Se R st# <br /> �y 3 r <br /> L10043-06 10/252021 A Iof R'cll;Nnn uPenne <br /> 13�G/. ` g CA CeJD SI�,S� <br />