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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 /> �s&4 fc/ <br /> JOB ADDRESS CITY/ZIP C�fI Q m <br /> CROSS STREET APN (/C�� KpARCEL SIZE O LAND USE APPLICATION# o <br /> OWNER NAME OGG��j /t�// / l 9 oph L PHONE q vi <br /> OWNER ADDRESS 3 /t/� Com- /[(n /,{/1 CITY/STATE/ZIP !r fA_/1t10Q <br /> CONTRACTOR 'It WL it <br /> �yPHO/N�E O1 <br /> CONTRACTOR ADDRESS J CY CITY/STATE/ZIP � (e_ e G'a 9,5.7 ge <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 C-61 D-09 Other NUMBER 9EXPIRATION DATE `O <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural : Industrial ❑ 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 #01�eplacemenl Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) #of borings Geotechnical #of 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 CONSTRUCTION <br /> Drilling MethodeAud Rotary Air Rotary Auger : Cable Tool ❑ Push Point Other <br /> Proposed Well Depth 106 ft Excavation 1,2 V <br /> in diameter ❑ Open Bottom �(Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1:; in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth__206 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) X9and Cement frr��3 sack mix/7 gal water <br /> Bentonite(20%solids) [A 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 ft Thick <br /> in = Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine C1 Other HP Pump Set 160 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. f'or Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE O LY <br /> Application Accepted By Date 7/ Area-J Employee ID# �� <br /> Grout Inspection By Date 21- nL;(� �� SPECIAL Well Permit <br /> Pump Inspection By /( Z >7^' Date 'z _ WAIVER ReCeiVedPigy� <br /> Soil Boring Inspection By Date Constructed Well Depth �'N ft <br /> COMMENTS�Dlaaes.r¢..�✓vY G� _PI% <br /> PE SC Received Check#/ Amount O Date Permit/ Invoice# We1111111w# <br /> Codes Info B Cash Remitted Service Request# FN QCIIIy <br /> I0 q��\23 WPB©�t1831 STH QA- <br /> (f.39/ /s ���12 wE�ocoyy 32 MEN <br /> 2 <o <br /> EHD043-0619/07,2022 /� �J\.. �_ff_ �1 ^�� �O��clo(2 Well/Pump Pcnnit <br />