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l �, 1 <br /> 0� <br /> EFAA E L E <br /> 1 WELL/PUMP 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 CITY��PLICATION <br /> m`1' W-7 <br /> `Q A <br /> CROSS STREET � 1�� APnNI1 D� ��_PARCEL SIZE # <br /> �I 'V �IY S m <br /> OWNER NAME <br /> PHONE 2(� 8"44 I2 y <br /> OWNER ADDRESS CftY/STATE/ZIP�Mi tQ' V <br /> CONTRACTOR ( III V � PHONE <br /> CONTRACTOR ADDRESS A� J CITY/STATE/ZIP 1•I/�&jj, . CA 15�q 7 <br /> SUBCONTRACTORPHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP ��j7f, <br /> LICENSE C-57 _ C-61 D-09 Other NUMBER EXPIRATION DATE ' ✓t/.�� <br /> DOMESTIC WELL SAMPLING:A General Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesticiPrivate ! Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner 'Nater System Name -— Contact Name or Phone Number tF 7- <br /> TYPE OF WORK New Well Replacement Well -_ Well Alteration/Modification Other D <br /> Monitoring Well(s) #of wells C Soil Bonn s s cr bonntt of s <br /> gO gs Geotechnical <br /> Out-Of-Service Well "7 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair - Raise Well CasingN J <br /> WELL CONSTRUCTIONVI N C <br /> Drilling Method nMud Air Rotary Auger, Cable Tool Push Point Other N�AL7-p NMENOU 7 <br /> Proposed Well Deplh _ft Excavation _in diameter Open Bottom y Gravel Pack/Gravel Size in dia T <br /> ConduCasing in diameter / Cond�ucj�r Casing Depth ft <br /> Well Casing Diameter n in Thickness/GaugelASTM Sched Up Steel Plastic Stainless Steel Other <br /> Grout Seal `9epth ' ft D Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ]Bentonite(201%solids) L Other <br /> iGrout Placemen{Method Pumped - Free Fall Other Retardant I 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 SubmersibleD Turbine Other HP Pump Set ft Standing Water Level f� <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 /> �IININIL NI.14 Hut R AD%AN('k N'011('f:REQUIRED FOR LV,,PECTIUXS-PLEASE CAL-I.t2090".'­_w; <br /> DEPARTMENT USE ONLY /`��`9 <br /> Application Accepted By Date <br /> L' Area �" �/ Employee ID# <br /> Grout Inspection By Date 9 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inft <br /> nsspection By Date Constructed Well Depth <br /> COMMENTS J t-- .-''r- t-"'z . :4"Z' c c'; <br /> 14 Vjuu� �t5evi. e - <br /> Vi <br /> PE SC Received Check#/ Amount Date PermlU Invoice# Well IDS <br /> Codes Info B ash Remitted Service Request# <br /> W B <br /> 1-H17073-0604.07-2022 I / [/..�79'7 PAP I of: SCANNEDWellPump Pcrmn <br /> ` `/P_ c� <br />