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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE P RMIT <br />CALL 209) 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />/j <br />"" W <br />CITYIZIP <br />/EXPIRES <br />CROSS STREET <br />I vie" APN ` 4 <br />Pnrt4CL SIZE <br />LAND USE # <br />OWNER NAME <br />LaPACa[t• M <br />, ISOn <br />�A�IPPPLIIIC�ATIO1NN <br />PHONE Z <br />�•��f ~4A5unfn <br />303in <br />T2 '.W- (v00 <br />��,•/ • <br />OWNER ADDRESS <br />CITYISTATEIZIP <br />1G,.. <br />� G 0� <br />•/�7,1�J�I�v <br />CONTRACTOR {V 1 <br />PHONE <br />r Ln <br />CONTRACTOR ADDRE(�SSS <br />CITYISTATE/ZIP <br />1 <br />of <br />TV/vW/�'� <br />Y�/ <br />- <br />�yf1���/'� <br />2 <br />925 1 <br />SUBCONTRACTOR �r�, {,{„ia <br />�/ r 1 `� <br />PHONE J <br />SUBCONTRACTOR ADDRESS <br />a _ <br />` 4 �%f,/ ^ <br />CITY)STATEIZIP <br />/(500 <br />m -t i • a. &Pc qq, .7 J <br />LICENSE -57 ❑ C-61 <br />- <br />❑ D-09 ❑ Other <br />NUMBER J 00 <br />EXPIRATION DATE W(�� <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) <br />❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sam pling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contac) Name or Phone Number <br />TYPE OF WORK ❑ New Well E Replacement Well I Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells L Soil Boring(s) # of borings Geotechnical of borers <br />-1 Out -Of -Service Well ❑ Out -Of -Service Well Renewal a Cross -Connection Repair /� <br />New Pump ❑ Pump Replacement C Pump Repair L, Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ra Air Rotary Auger I I Cable Tool L Push Point Other _ <br />Proposed Well Depth 10 ft Excavation in diameter t Open Bottom I Gravel PackiGravel <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknP-vslGaugefASTM Sched I Steel i Plastic ❑ Stainless Steel <br />Grout Seal Depth Io Neat Cement (941b bag/5-10 gat water) ❑ Sand Cement - <br />0 Bentonite (20% solids) I I Other <br />Grout Placement Method C Pumped - Free Fall ❑ Other ❑ Retardant I Accelerator (name) <br />N <br />m <br />D <br />A <br />m <br />in <br />N <br />'may/ I <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />J Concrete Pedestal ❑Dimenslons: Width ft Length ft Thick <br />�In i7 Christy Box '- Stove Pipe <br />PUMP ❑ Submersible❑ Turbine L 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, strnetures, <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 />MINIMUAi 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By��fv`' <br />CQMMENIn <br />TS - / (em I e n i DG40dri, <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Dale <br />Area 3 4�II� Employee ID#S <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Connfructpei Wpll D# -nth ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#I <br />Cash <br />Amount Permit) <br />Remitted Dat _Service Re uest # Invoice # Well ID# <br />37d <br />5.0 <br />Sti <br />rr <br />V33 4 Ll 30VI- DM� <br />14 <br />EH D043-06 1012.5/2021 Page 1 ort Well f Pump Pemlil <br />146q 2 � <br />