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r <br />c ' <br />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 c CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS Z&(_Q I `POnasco rr'' (oo_,d CITY/ZIP � r <br />CROSS STREET APN 0 8+ ?d O O Lf) PARCEL SIZE f ' q S LAND USE APPLICATION # <br />OWNER NAME Ailne J ! 1 M j 0h PHONE <br />OWNER ADDRESS / !� 10 �Q� 7 <br />li�ljkm CITY/STATE/ZIP c� l C% <br />CONTRACTOR U l r ( / c HONE aV ! / C) <br />CONTRACTOR ADDRESS C� I d O I CyN CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CIITYYJ/SSTATE/ IP 2 <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER V/U s EXPIRATION DATE ✓� <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE I,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 Bo6ng(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pum 41. Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 !b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other ❑ Retardant / Accelerator (name) <br />)EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: Width ft Length ft Thick <br />❑ Christy Box ❑ Stove Pipe <br />PUMP OLSubmersible❑ 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 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 />N11\ 11It \1 2-1 H01 1, ADVAN( F V'0T1('E REQ(IRED FOR INSPECT IONS - PLP_ASE ( XI_L (209) 9_53-7697 <br />�+ 1 1 DEPARTMENT USE ONLY <br />Application Accepted Byy /-'—Ly [ Date /3 aZ o?Area Employee ID# r c f, -,ilk I <br />Grout Inspection By 4 A Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date (� ❑ WAIVER Racei d <br />Soil Boring Inspection By Date Constructed Well Depthft • ft <br />COMMENTS Doc vyoert f roG rr4) na le -4 6r Wp I 1 1 —1 ) i .l <br />PE SC Received Chec ! Amount Permit/ <br />Codes Info B ash Remitted ate Service Request # Ini6e # ��I IID# <br />39i oso 47-7 X32 WP004 8 Nei c <br />DEp NT <br />IiiZ <br />ENT <br />EHD043-06 1085/2021 Page I of 2 Well / Pump Permit <br />