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EMAILED <br /> ace-ace Q <br /> 1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)46"420 <br /> NON-REFUNDA13L//E�PERMIT /� ,^'CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> !JOB ADDRESS ,,-I NON 1�1 L�yr/ CfTY/zlP - �h('r�my gN-2( _ <br /> IICROSSSTREET"VNJ(Jt� I w APN 100 1 / PARCELSLZE�A LAND USE APPLICATION# <br /> ltN a N Yl OWNER NAME [j. `j� '7 CO,' _ _ �`^ PHONE ]�11����'�''I��r� n� <br /> OWNER ADDRESS I > T 1 7— ` 1r C(TY/STATE/ZIP , X V'`Q rA 1 zoV <br /> CONTRACTOR N A S01I1S ��yl��[y//Y��II 11 I�l^ J N t/ PHONE � 1-/ (��/�j 2_12 7 <br /> CONTRACTOR ADDRESS lNq r ( I►7 V 1'�a Mi CITY/STATE/ZIP M O , (A 1�/✓ + <br /> SUBCONTRACTOR 1g- PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATEIZIP <br /> LICENSE C-57 _ C-61 "I D-09 I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:kGeneral Mineral/Coliform Bacteria(4391�Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural -- Industrial _ Water Quality Monitoring ISoil Sampling/Characterizati <br /> Public Water System �7VAN <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> -- --- <br /> TYPE OF WORK }( New Well Replacement Well Well Alteration/Modification a Other D <br /> Monitoring Well(s) #of wells "] Soil Boring #Of s) borings Geotechnical �'T,4;7- <br /> Out-Of-Service Well Out-Of-Service Well Renewal El Cross-Connection Repair /j S <br /> New Pump Pump Replacement Pump Repair C Raise Well CasingJ �Q <br /> I WELL CONSTRUCTION <br /> Drilling Method Mud Rota -tAir Rotary Auger Cable Tool _ Push Point Other H HROAMEN U 7y <br /> Proposed Well Depth It Excavation J 1, in diameter ❑ Open Bottom X Gravel Pack/Gravel Size_in r T <br /> Conductor Casing in diameter / Cond t.Q�Casing Depth ft <br /> Well Casing Diameter i Thickness/Gauge/ASTM SchedW r Steel X Plastic D Stainless Steel Other <br /> Grout Seal Depth' ft Fl Neat Cement(94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br /> �Bentonite.(20%solids) ❑ Other <br /> Grout Placement Method Mumped '7 Free Fall J Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By "- Driller Pump Contractor 1 Other <br /> Concrete Pedestal Dimensions:Width it Length ft Thick <br /> in Christy Box C Stove Pipe <br /> PUMP Submersibles Turbine Other HP Pump Set 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, dater 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«ater wells or surface water within 200'radius of proposed well. <br /> N1 24 HoL k.ALA AN(:L.N011(-1.I(i.tl(IRUD 1-(!k I t I IONS-PLLASL CALL(20t S:3-76,,- <br /> DEPARTMENT USE O //LY <br /> Application Accepted By w Date 2 Ill Area Employee ID# rJT <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> St �COMMENTS s n <br /> 1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By., ash Remitted Service Request# <br /> va 2100 <br /> .� <br /> a <br /> EHDO43-06"07f2022 '�I� �O�I ZI b b,),1f'ljt�l oft Nill Pump P,—,l <br /> OCR/ T t <br />