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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 />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I-1-10 <br />CROSS STREET 1 VA F <br />OWNER NAME �h <br />OWNER ADDRESS i <br />CONTRACTOR NSW Y <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/ZIP <br />APN d D U 3 300'7 PARCEL SIZE 11 LAND USE APPPLLIICAATION # <br />irY e-2 PHONE �V <br />CITY/STATE/ZIP (j <br />LICENSE j?C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITYISTATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER qbg Ema EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE P 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 />Amount Date Permit/ Invoice # Well ID# <br />Remitted I I ervic Re u t # <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br /># of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Z"Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />PAYMENT <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 <br />Size i i r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ OtJAN 10 207 <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />SAN JOAQUIN COLIN <br />Grout Placement Method ❑ Pumoed ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />ENVIRONMENTAL <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 Submersible❑ Turbine ❑ Other HP_J 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 />NIINI;NIt M 24 HOUR ADVA\CE V'O"LICE RLOLIRED FOR INSPE.C'I IONS - PLEASE, ( ALI. (209) 953-7697 <br />T DEPARTMENT USE ONLY <br />Application Accepted By �/ ` Date i O a0? 1 <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Date 1 I Z,-) ( 7—'L— <br />Area 3j Employee ID# ,1 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS L — Pct <br />PE SC Received Check#/ <br />Codes Info By Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted I I ervic Re u t # <br />93191 SO <br />7 <br />rRD043-06 1025/2021 Page I of 2 Well / Pump Permit <br />