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1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY FjmRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CAS5205-(249)468-3420 <br /> NON-REFUNDABLE PERMIT // CALL 209 953-7697 FOR INSPECTIONS "EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOE ADDRESSrl CITYIZIF�tli� 95 3 0 m <br /> CROSS STREET APN_ I F 7-3 2.y0(O PARCEL SIZE tJ3ND USE APPLICATION# p <br /> OWNER NAME T _nd c�, lea,tt1@ ate_ jig] PHONE 209-327-3232 w <br /> OWNER ADDREss 334 halako QTY1STATEOFOakdale CA 95361 <br /> CONTRACTORI?urviance Drillers, Inc PHONE 209-887-3554 <br /> CONTRACTORADDRESs PO Box 64 CITY/sTATEZIP Linden, CA 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE Xr C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 377923 ExPIRA'noN DATE 7/31 /2 5 <br /> DOMESTIC WELL SAMPLING.!'General Mineral/Coliform Bacteria(4391)i) Dibromochloropropane(4392)_!Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private><Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring ❑Soil Sampting/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ NmWell ❑ Reptacement Well ❑Well AlterationlModification ❑ Other <br /> ❑ Monitoring Wells) #of wells D Soil Boring(s) f of borings ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement Ptmtp Repair ❑ Raise Well Casin DrIl <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary Q Auger ❑ Cable Tool ❑ Push Point D Other Sq N JOA 2023 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D Gravel Pack/Gra 60" meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft Epq R r74 y <br /> Well Casing Diameters in ThicknesslGaugelASTNI Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Meat Cement(94 1b ba96-10 gal water) ❑'Sand Cement sack mW7 gaMFNil water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fail 0 Other ❑ Retardant(Accelerator(.,lame) <br /> PEDESTAL Instatied By ❑Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length R Thick <br /> In ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine D Other NPS Pump Set 190 ft Standing Water Level / Z ft <br /> Plot Plan Requirements: Mtach�a plot plan with the exact Iocation 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,ilculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed weIl. <br /> &1 slluDi 2d riOUR ADV4_rsCE NOnCE REQLTMED FOR LNSPECU0NS-PLEASE CAT_1 (20�-)953-7697 <br /> DEPARTMENT UZ�,E OJ4LY /q <br /> Application Accepted Date , ' g � Area r ( � Employee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Date PermiU invoice# Well tt3#! <br /> Codes Info B Cash Remitted Service Re uest# <br /> 113171 DSO !; = 077 '12-011_5 WPI T40NZ <br /> EMM43-06 0-Vola0ZI 1-7-3-3 i �G) P <br /> - <br /> Q <br /> " <br /> 0 <br /> f3 well IRump Perini., <br />