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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 PERMIT CALL 209 5\3d-776,97 FOR INSPECTIONS EXPIRES <br /> 1/YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS CIN/ZIP 0 V l v�'f/�L/ ` J��t!J m <br /> CROSS STREET v'T d(' rlAPN VV� l y v PARCEL SIZE��I LAND USE APP CATION# o <br /> 'r m <br /> (� m <br /> OWNER NAME /,� PHON� 0 <br /> OWNER ADDRESS &'V CITY/STATE/ZIP ��/f ( /'� <br /> CONTRACTOR GCts�-(t 11yo^N�at 1�(n�I[l► n �j PHONE _ `j l.e t. of V K <br /> CONTRACTOR ADDRESS 'J I`r`"[ t(/ CITY/STATE/ZIP�),I Uy),19 V 1 CI,)C"H % (j/7 <br /> SUBCONTRACTOR t PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP G� <br /> LICENSE C-57 ❑ C-61 1i D-09 I.1 Other NUMBER I✓ ✓ EXPIRATION DATE17_(f CD-D_ <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria(4391),X Dibromochloropropane(4392)k Arsenic(4393) <br /> INTENDED USE 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 N New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ❑ Soil Bodng(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodX Mud ❑ Air Rotary ❑ Auge ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depi ft Excavation — in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> 11Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well CasingDiameter In Thickness/Gauge/ASTM a/ASTM Sched ❑ Steel X Plastic ❑ Stainless Steel ❑ Other <br /> 9 <br /> Grout Seal Depth.ann _ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> A-Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By _7 Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick T <br /> �in ❑ ChristyBox ❑ Stove Pipe D <br /> Pump =i SUbmersibleJ Turbine ❑ 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 110 <br /> �aS2 22 <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. j(,CC UNTY <br /> Agriculture, Industrial well,provide location of any water wells or surface water within 200' radius of proposed well.ENVIRONMEN AL <br /> .N11.NIV1UM1t 21 IiOIiR ADVaN(:H:NO'17CE RISQt Iltl•:D FOR IVSPN:('"1 t0Nti-I'LF;AIF;(',11,1.(209)953-7697 <br /> HEALTH DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / J?e� Area Employee ID# (7 <br /> l Date <br /> Grout Inspection By OV2 <br /> Date ?jZ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS b yiSf-w�, WeII b6,, rtf-, IroV,, - (I nc;/fi ✓V»,� Nt, e Ho ,recorc's aFst pl c <br /> X11 4eir► 1a norfj; �'t1rJ�.G,J-nr [ e t14enl li,—a �1a?? c,��rC �1CA� @ 2l01 <br /> PE SC Received Check#/ Amount D e Permit/ Invoice# Well ID# <br /> Codes Info sy Cash Remitted Service Re uest# <br /> o a o 1 <br /> 3G{ I ISJ u <br /> �I3q� 4 70 <br /> y3�q3 If 19,0I• <br /> EHD0434)6 10252021 �!_�I �OO�("� ��` \�c I o1`2 Wcll/Pump Pcrmii <br />