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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468420 <br /> NON-REFUNDABLE PERMIT /� ''C_A.LL 209 953-7697 FOR INSPECTIONS rEAXPII'RES 1 YEAR FROM DATE ISSUED <br /> Cn <br /> JOB ADDRESS Z /yr T/�/� /lam CITYIZIIP 46 d/_ /IL�J� L/}. 453;417G� m <br /> CROSS STREET ?2/4N'/DN APN7,�4_D30 • PARCELSIZE4 -LAND USE APPLICATION# o <br /> J <br /> pa <br /> OWNER NAME �oPJE2T d!' /q/V3C7/NE� r/C PHONE&00 &* - 7117,Q y <br /> OWNER ADDRESS X36oc /�'� �� R—d CITY/STATE/ZIPGS��}^��/, ( •T`��IZ� • 7 <br /> CONTRACTOR `�N�72�' �Ns �'yG• PHON(/ n —//'34 <br /> //34 <br /> CONTRACTOR ADDRESS ` 7 r � CITY/STATE/ZIP :O,yezA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7 EXPIRATION DATE Z Z 3, <br /> Lx 7— <br /> DOMESTIC WELL SAMPLING:W.,General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural G Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK INew Well X Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 0 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 41P40 ft A Excavation I in diameter ❑ Open Bottom ;(Gravel Pack/Gravel Size Z-� in diameter <br /> Conductor Casing 119 in diameter / Conductor Casing Depth /Q ft <br /> Well Casing Diameter 8— in Thickness/Gauge/ASTM Sched SQR 17 ❑ Steel )(Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth 1-00 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method (Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller I;KPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ftThick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ;'Submersible[] Turbine 0 Other HP Pump Setj_ 0 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 /> MINIMUM 24 HOUR ADVANCE NOTICE RF.QITIRED FOR INSPECTIONS-PIXASF.CALL.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By G Date 1 Z z Area i l <� Employee ID# /Z <br /> Grout Inspection By AZ Date T/� ❑ SPECIAL Well Permit <br /> Pump Inspection By It i � Date 1-r- ' �� ❑ WAIVER Received I"q <br /> Soil Boring Inspection By Datelo p L1-bZ�onstructed Well Depth r <br /> COMMENTS 014 4 1,)-r 11-) ReLold, _ �N �► ^.I Y`^c; F h cIJ i' PS LL <br /> PE SC Received ec Amount Dat Pe It/ Invoice# J, '/'ID# <br /> Codes Info B ash Remitted Service Request# E <br /> L 8(jI ! T NA. OU <br /> '43 70 O U w 2 2 'wT <br /> EHD043.06 10/25/2021 Page 1 01`2 ((1G �--�p�� ����� well/Pump Permit <br />