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I 175010 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />MUIY-11111:1UNUAtILt rtKMI I koALL (ZUV) V*.$-fOWf FOR INSPECTIONS t7LYIK1ZS 7 TEAR FROM DATE ISSUED <br />.108 ADDRESS ' g (�- .JiNIJ� <. ? . - --G -- - ---- — CITY/LP �&-W'-' 0 I <br />CROSS STREET APN 14DQ 1-J PARCEL SIZE 15.41 LAND USE APPLICATION # - <br />OWNER NAME r I(}y��+ P�j�Yle►'�jht� PHONE__ - <br />OWNER ADDRESS (�1 101 14x1A <br />9 e 619 _ _ CITYISTATE/ZIP EA' �\ U f nk 1h't 5 330 <br />CONTRACTOR N I L 6AU50, A °Cel ftat.Ar, ) PHONE (09) 363- 3901 <br />CONTRACTOR ADDRESS _ 9 O Q- T^rAkl) j \'C I Q�. J JO''M_ �l CITY/STATE21P_LBctt , C'n, <br />i <br />SUBCONTRACTOR _ N1(A PHONE NIA <br />SUBCONTRACTOR ADDRESS N R _ CITY/STATEIZIP N %Pt <br />LICENSE S C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 6 (ns wi EXPIRATION DATE 51 AI ) 202 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1.. New Well ❑ Replacement Well ❑ Well Atteration/Modification ❑ Other <br />Monitoring Well(s) # of wells Soil Boring(s) — # of borings III Geotechnical 5 <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Li New Pum __❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing _ <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary L Air Rotary IN Auger Cable Tool �i Push Point _ Other <br />Proposed Well Depth__ Z0, _ ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft <br />_# of borings <br />_ in <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ! Steel C Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth al)' ft a Neat Cement (94 Ib bag/5-10 gal water) :, Sand Cement_ _-_ sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped Id Free Fall ❑ Other I Retardant / Accelerator (name) <br />(PEDESTAL Installed By ElDriller ❑ Pump Contractor ❑ Other <br />11Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />u P ❑ Submersible❑ Turbine n 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �� Date3/„7.2 <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS 1 (C w- I e f <br />Area_ 1 C1� Employee ID#- Frefli'llf <br />❑ SPECIAL Well Perl to <br />❑ WAIVER ReceiveR MENT <br />PE SC Received <br />Codes Info B <br />eck#/) <br />Amount Invol Permit/ „�/�„ T RpN Iry <br />Remitted Date Service R ues <br />�13 7D ) <br />2 <br />)) 00 IN L <br />`fR7,&q - <br />EHD043-06 10252021 Page 1 of 2 Well / Pump Permit <br />