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EMAILED <br /> Z <br /> WELL/PUMP PERMIT <br /> SAN C y� V E1`4L(ILT DE <br /> PARTMENT, PARTMENT 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 C1 0 l � �LQ�—�.��y� � i' ( L <br /> VK <br /> a CITY/ZIP �� C IG`>�011 rf� m <br /> CROSS STREET / r��►/)LV1'� APN U`fF1�l-^ UG(I ^ ,�, D <br /> PARCEL SIZE C LAND USE APPLICATION# <br /> 0 <br /> / i_ �y <br /> OWNER NAME m <br /> (�� (�rL1'TI{�r��� PHONE <br /> -�s� y <br /> OWNER ADDRESS \� �, cGt ( (V s CITY/STATE/ZIP 2;�HOVC e--t]2n /CS �S+ <br /> CONTRACTOR �1 { �ti��{ Dor 1 t t1 l� PHONE 2VA Cl C G 1 t/4 <br /> ii r-7 . 1 <br /> CONTRACTOR ADDRESS �� Jam(✓L��"(� I(-. <br /> SUBCONTRACTOR CITY/STATE/ZIP� C�, <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 C-61 G D-09 U Other NUMBER104-Lf, 4� EXPIRATION DATE C�` 3111' <br /> DOMESTIC WELL SAMPLING: general Mineral/Coliform Bacteria(4391) ibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE X 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 4ew Well Replacement Well U Well Alteration/Modification Ll Other <br /> U Monitoring Wells) #of wells I—- Soil Boring(s) #or borings _. Geotechnical #of borings <br /> U Out-Of-Service Well ,I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pum2 Replacement U Pump Repair ll Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method V Mudotaf� Air Rotary ' Auger 0 Cable Tool U Push Point U Other <br /> Proposed Well Depth_I C ft Excavation i-1 in diameter Open Bottom A Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Con uct r Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schec W2-1 Steel XPlastic _: Stainless Steel Other <br /> Grout Seal Depth 1 1 ft Neat Cement(94 Ib b8g/5-10 gal water) 5 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method i-+".16umped '_ Free Fall Ci Other fRetardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller - Pump Contractor 7 Other <br /> C Concrete Pedestal_Dimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP U 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, 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 /> 111\1 Nil tI �4 tart V *t/\ 1:N('1':1(.)t'i( I:RI:Qj WED D I OR I`;St`3if I IONS- AAI. <br /> DEPARTMENT UUSENLY r <br /> Application Accepted By Date f`0 �Z� Area Employee ID# �! — <br /> Grout Inspection By Date 'I� II SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS r <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoic1161, <br /> 7° I 3 ZfoW rz I 6 <br /> �f39/ <br /> V/ Qi✓ <br /> ci <br /> ti M o <br /> qR q< <br /> EIIU043-06(A/01;'2022 21 -tj p loaded into Ac c e I a �L'ell 1 Pwnp P�Tmil <br /> I <br /> N �� ��, <br />