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1 WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIIT� CALL 209 953-7897 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESSC `11 Ll CITY/jJPf C/�I�) G�J7J LIJ m <br /> CROSS STREET J V APN _ I�LJy!�V PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME J I PHONE I1 <br /> � 0 m <br /> OWNER ADDRESS � LJV 1 I U+ I N CITYISTATE/Z1P I N <br /> CONTRACTOR V\XV' 1J �Y 11'1k )](/.n LJ PHONEl�) 9 <br /> CONTRACTOR ADDRESS I I � CITY/STATE/71P (/1 Gl <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER U7- ExPIRAnON DATV4' 3O'Z3� <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)P Dibromochloropropane(4392) 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 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Cf-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 Method [ Mudof C Air Rotary 0 Auger I; Cable Tool ❑ Push Paint ❑ Other <br /> Proposed Well Depth_ bft Excavation _ , in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct% Casing in diameter / Conductor sing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sc hed Conductor sing <br /> ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth�ft ❑ Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix17 gal water <br /> ent •t (200/, solids) ❑ Other RAY MENT <br /> Grout Placemen Method umped ❑ Free Fall ❑ Other ❑ 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 w' ukolg <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Watea+ 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 weH,provide location of any water wells or surface water within 200'radius of proposed well. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Z—Z— Date* Employ <br /> /2 Area � ee ID# a fes" <br /> Grout Inspection By Date��(�t�Q���2 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 17 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth' 3z'Depth ft <br /> COMMENTS r-IP 11-1 j WLR <br /> 1Z, / v12 th e, -�- I St1 w o <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> LHDO43-06 10,15/2021 �--�U 3 S `f' hgc 142 �� - �-C'P� �.1�"— WcllI Pump Permit <br /> 3t� r2r2'�- <br /> lll <br />