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Z ' WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL !HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFIIN_DABLE PERMIT %/ � CALL (209) FOR INSPECTIONS _ EXPIRES 9 YEEAR]^ FRom DATE ISSUED <br />JOB ADDRESS 75i) ��2 �"& ZVD / r L`+�/ ---- --- CfTYiZ1,q3 <br />IP <br />CROSS STREET � , � �J' APN V Gl `-"' 3 0 PARCEL SIZE r 1 q 3 LAND USE APPLICATION # <br />PHONE 1 G- y' �� � - 2 <br />OWNER NAME L --- ---- <br />OWNER ADDRESS /yI� CITYISTATEIZIP <br />PRONE —1 1 �% <br />�(J <br />CONTRACTOR ADDRESS l / e6 ✓ i l 00 (/ -2C CiTY1STATEIZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />LICENSE i i C-57 IG61 D-09 Y. Ether / NUIMBER r, '5 ! - EXPIRATION DATE '8131/2V <br />DOMESTIC WELL SAMPLING: D General MineraliColiform Bacteria (4391) ❑ Dibromechloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private -, IrrigationrAgricutural - Industrial Water Quality Monitoring Soil SamplrnglCharactenzauon <br />i Public Water System <br />�f d fferer' from 0 lef-,er Wa'.er System Name Contact Name or Phan Number <br />TYPE OF WORK New Well :3 Replacement Well L! Well AlterationlModification i -i Other <br />Monitoring Wells) # of wells C Soil Boring(s) # of =trigs f . Geotechnical r ' °D`t1CJ5 <br />Out-Of-SerAce Olell G Out-Of-Service'!Jell Renevial Cross -Connection Repair <br />New Pump Vpmp Replacement 1,1 Pump Repair -t Raise Well Casing <br />Drilling Method ' P:iud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation _ in diameter I ? Open Bottom Gravel Pack/Gravel Size _ in diameter <br />Cndl.sctcr Casing in diameter 1 Condlxtor Casing Depth.- ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel _i Plastic ! Stainless Steel 1 Other _ <br />Grout Seal Depth ft tj Neat Cement (94 Ib bag/5-10 gal ivater) !-1 Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Li Other <br />Grout Placement Method Pumped i Free Fall C; Other Retardant /Accelerator (name) <br />PEDESTAL Installed By DrMer Pump Contractor Othor <br />I -I Concrete Pedestal: !Dimensions: Width ft Length ft Thick <br />in a Christy Box u Stove Pipe <br />pump P Submersib!e 'I Turbine Other HP Pump Set _ ft Standing Water Level "'&6 _ ft <br />Plot Plan Requirements: Attach a plot Plan with the exact location of water well with respect to iht folto�ving 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 />J DEPARTMENT USE ONLY <br />1 <br />Application Accepted By _ Date <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By r <br />COMMENTS Dom/ -0N%� } / •DD i (_, o7 6,, f S UI <br />Date _ <br />Date <br />Date <br />T <br />D <br />v <br />v <br />s <br />Area—'-/ / / Employee ID# <br />❑ SPECIAL Well Permit <br />F WAIVER Received <br />Constructed Well Depth <br />1-1 L " Z ) LAt� - <br />tt <br />PE SC Received Check#/ <br />Codes Into By Cash <br />Amount Permit! Invoke Well IDX <br />Remitted Date Service Request # <br />V <br />i fl ��IG 10 <br />75 <br />f:1100113-0610,252021Yagt 1 oft wil/PumpP ono <br />