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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE HERMIT GALL ZU9 953-/691 FOR INSPECTIONS EXPIKES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Z �9 E G��ro kee P'6- CITY/ZIP S, f pC,�c f0() R 52' 5 <br />CROSS STREET APN � // pp 3 � 0 PARCEL SIZE 07'Y7 LAND USE APPLICATION # <br />OWNER NAME �J�a(Y�]laQ�1 C1yr/�j_ l rUEC� N KArG PHONE 1-011 -40(0 p- L114FY <br />OWNER ADDRESS �ZTJ -/ 1,,, (,InAQ1ialI�QQ.Q' 9d. CITYISTATE/ZIP S� 5bil CA 715ZI-5— <br />CONTRACTOR IAooyrY los 1 VvQ•'tf//il'�� �l{S�LI{�S [VIC. 1P,HONE tr(/-`-A� _`3l' ;w C) <br />CONTRACTOR ADDRESS ZIZO W 1� COX I�Li CITY/STATE/ZIP tS-IU(,�c pr) CA 9,4 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />PHONE <br />CITY/STATE/ZIP <br />LICENSE 5r. C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER QV8 p1 (f EXPIRATION DATE A51 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Ild 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 ❑ New Well ❑ 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 />❑ New Pump 9( Puma Replacement ❑ Pump Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION c <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other I�AY�G�T <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size—„^�aOr <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement n a a er <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) SAN JCIP.0 .t�eFNTA� <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other HEALIM Ute' ' <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ 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 />MINI N11 Nl 24 HOLR ADVAV F \OTICE REQL]RED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY '- <br />Application Accepted By �� L�� Date I/ Area M1 Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date 2J -L-- ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />D <br />0 <br />A <br />m <br />CA <br />PE <br />Codes <br />SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />In Cash Remitted Service Re # <br />sl <br />-quest <br />a sb Z <br />EED043-06 1025/2021 Page I of 2 Well / Pump Permit <br />