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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 PERMIT UALLZUy !Jb3-/bUf FOR INSPECTIONS EXF'IKL5 1 YEAR� FROM DATE ISSUED <br />JOB ADDRESS 0 / CITY/ZIP flaw, <br />CROSS STREET rAPN 8(�S3 O f 6 PARCEL SIZE f y �f LAND USE APPLICATION # <br />OWNER NAME cvo PHONE�`���LJ�� I F <br />OWNER ADDRESS tdreth CITY/STATE/ZIPfl-a.CIO �✓ l4/1 <br />CONTRACTOR PHONE (P— 3I`^30 —cl <br />CONTRACTOR ADDRESS ^ CITY/STATE/ZIP�C(b�W ��dl.Cal <br />SUBCONTRACTOR n ) /�L PHONE <br />Y� <br />SUBCONTRACTOR ADDRESS ITY/STATE/ZIP <br />LICENSE XC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE XDomesticlPrivate ❑ 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 ❑ Pump Replacement Ypump Repair AnQ:2!— ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft 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 X Submersible❑ Turbine ❑ Other HP _-J _ Pump Set ft Standing Water Level ft <br />Plot Plan Re uirements: 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 />NUNTIML'M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION'S - PLEASE CALL (209) 953-7697 <br />s DEPARTMENT USE ONLY <br />Application Accepted By �� L� Date la a a <br />Grout Inspection By A Date <br />Pump Inspection By ^ Date 2 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area I c/ q q Eaft e ID# fru n k <br />❑ PECIAL We f <br />11 WAIVER ReCe L�® <br />Constructed Well Dep*Fo O w ft <br />PE SC Received (CKeck#P Amount Date Permit/ Involc �F7DE NT�Alell fD# <br />Codes Info BV Remitted Service Re uest # ARj <br />3V 050 -7-7 2.2.2 ODy2 5 <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Pennit <br />T <br />m <br />0 <br />0 <br />X <br />m <br />to <br />