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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />14UN.MLI UNDABLE PERMIT (:ALL (ZU9)9b3-[b91 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS (� l� CITY/ZIP <br />CROSS STREET n� APN 1. I lC PARCEL SIZE i ' LAND USE APPPLLIICATTI^OONv# <br />OWNER NAME, Q� PHONE�-�L <br />OWNER ADDRESS `7501/�,b1 r1�1,, V L C� �/�/� C/frY/STATE/ZIP �/y1/�`19Cl% 't(/ai/2l //�) <br />CONTRACTOR MIC rnn'1 " 1 A It C 7. � Ck t I I � \ rl C. PHONE ✓Y V / ' ! 1i /— 367/]` J <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS 1 N <br />LICENSE S1 C-57 f_I C-61 I] D-09 <br />Other <br />C rrY/STATE/ZIP <br />I <br />PHONE <br />C rrY/ (STATE//Z, IP <br />NUMBER "i (a 0 KI (0 EXPIRATION DATE / /-;v <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE KDomestic/Private I Irrigation/Agricultural ❑ Industrial 11 Water Quality Monitoring F Soil Sampling/Characterization <br />F Public Water System <br />If different from Owner: <br />System Name <br />Contact Name or Phone <br />TYPE OF WORK E New Well F Replacement Well E Well Alteration/Modification [I Other - I -& <br />Wo <br />C s # Monitoring Well(s) # of wells C Soil Boring # of borings s 17 Geotechnical of be <br />Out -Of -Service Well E Out -Of -Service Well Renewal tl Cross -Connection Repair Ze <br />1. New Pump )CIPump Replacement E Pump Repair D Raise Well Casino SAA, . J <br />WELL CONSTRUCTION Z'M"`tQUIN <br />C <br />Drilling Method I Mud Rotary I Air Rotary fl Auger fl Cable Tool f I Push Point I I Other y lHR f�MFNTUN y <br />Proposed Well Depth ft Excavation in diameter I1 Open Bottom F Gravel Pack/Gravel Size 'diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft / <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I I Steel 1:7 Plastic [IStainless Steel 0 Other <br />Grout Seal Depth ft I Neat Cement (941b bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) i. Other <br />Grout Placement Method L I Pumped ! Free Fall 1, Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By E Driller F Pump Contractor 11 Other <br />I Concrete Pedestal [ ]Dimensions: Width ft Length ft Thick <br />in 1. Christy Box 1: Stove Pipe <br />PUMP f Submersible Turbine I 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 />1II VI11iUA1 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2oq, 6.i-769 <br />E ARTMENT USE ONLY <br />Application Accepted By - Date �; Areae Employee ID# <br />Grout Inspection By v Date D SPECIAL Well Permit <br />Pump Inspection By / Date �- D WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />PE SC Received Chec Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Remitted Service Request # <br />EHI)(M346 10/25/2021 Pab� t or 2 W.11 i Pur, Permit <br />ft <br />