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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IW EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />IYUN-1111:1UNUABLE PERMIT GALL LUy V0,5-/byf FOR INSPECTIONS tArIKtS l TEAR FROM DATE ISSUED <br />Jos ADDRESS "7052, Y—al s -e v AZA, CfTylhP 5fsc khe <br />CROSS STREET S L! '-O h` <br />-� <br />APN V <br />JI - 0-1 y �/V PARCEL SIZE / -W&AND USE APPLICATION # <br />Grout Inspection By//,; <br />,� <br />OWNER NAME 1 Y1A it <br />N <br />st <br />O -n <br />PHONE <br />OWNER ADDRESS ZSSV <br />S • <br />T466A -e <br />10, CITY1STATEMP M pYttec <br />CONTRACTOR j� AS{ 11 1'f <br />6 <br />r;b I A ( xv�c- <br />PHONE 5 1 l <br />Z iJ <br />CONTRACTOR ADDRESS -1101 R <br />16e <br />! S 6A i <br />CITY/STATE/Zip <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE )( C-57 ❑ C-61 ❑ D-09 D Other. <br />PHONE <br />CCrTY1STATEIZIP J <br />NUMBER Ei 1� EXPIRATION DATE S J v <br />DOMESTIC WELL SAMPLING:: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Li Arsenic (4393) <br />INTENDED USE 0 DomeslicJPrivate mgabon/Agricuttural ❑ Industrial Fi Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C 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 11 Other <br />❑ Monitoring Welt(s) # of wells ❑ Soil Boring(s) i Or °onngs ❑ Geotechnical o of Donngs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New PUMD ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br />Drilling Method ud❑ Air Rotary D Auger ElCable Tool ❑ Push Point ❑ Other <br />Proposed Well epthoft Excavation tl in diameter [-1 Open Bottom Gravel Pack/Gravel Size I U in diameter <br />D Conduct Casing in diameter Con or Casing th ft <br />Well Casing Diameter n Thickness/Gauge/ASTM Sched j t tee] ❑ Plastic ❑ Stain S I ❑ Other <br />Grout Seal Depth_ ft ❑ Neat Cement (94 lb bagl5-10 gal wate� , `i Sand Cement sack <br />lu <br />❑ Bentonite (20% solids) L, Other 1` /� <br />Grout Placement Method YPumped ❑ Free Fall ❑ Other U 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 D Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Levdl'7 UFn:�1V )N <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: <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 <br />-� <br />Check#/ Amount Date Permit/ Invoice # <br />Cash Remitted Service Request # <br />Date _3 % d '� <br />Grout Inspection By//,; <br />S <br />�r �' <br />r Date 4L Z <br />Pump Inspection By <br />Date <br />Area H �V C„ Emplloyee ID# /moi 6 <br />❑ SPECIAL Well Permit <br />rl WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS -' ctt o;jj e,,6IP 1I C�'r rn�r rt^LtO� ��P �r "iP <br />7 1— <br />ur <br />m <br />m <br />13D <br />0 <br />M <br />m <br />m <br />N <br />N <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Date Permit/ Invoice # <br />Cash Remitted Service Request # <br />Well ID# <br />4649 <br />1 <br />^ <br />LH1304}06 1011-5.2021 ��'�/� /%� � / �'/y,�Pya/ge I oft N'cll! PurtQ Pemi't <br />