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I1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMIJ <br />JOB ADDRESS <br />CROSS STREET L,� fflo <br />OWNER NAME /I <br />OWNER ADDRESS ✓C� <br />CONTRACTOR <br />jn <br />CONTRACTOR ADDRESS C C <br />UO3-[bUI FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />1'I"yrilz -) CITY/ZIP.lam 7VOU <br />APN O 06 PARCEL SIZE ' e O LAND USE APPLICATI N(## <br />' <br />PHONE n- -140 6(S-0 <br />CITY/STATE/ZIP5ttetm Cp <br />PHON"2ffiQ )I —9vnn <br />CITY/STATE/ZIP 5 CA 9C C15- <br />SUBCONTRACTOR x � & PHONE <br />SUBCONTRACTOR ADDRESS ' CITY/STATE/ZIP <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 4L920 EXPIRATION DATE S. 1 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />I INTENDED USE V*4Domestic/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 Borings) # of borings ❑ Geotechnical # of borings <br />❑ Out-Of-ServiceIl ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump X PUmD Replacement ❑ PumD ReDair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <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 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP )Q Submersible❑ Turbine ❑ Other HP,L Pump Set / Y V ft Standing Water Level 177 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 tines, 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 REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By �/zz- <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date a a� <br />Date �L <br />Date�- <br />Date <br />Area Employee ID# Ff4vi k <br />❑ SPECIAL Well Permit <br />❑ WAIVER <br />Constructed Well De <br />Service Request# UP --;- . <br />ft <br />EHDO43-06 10!3!2021 Page I of 2 Well / Pump Pennit <br />