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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />II <br />JOB ADDRESS 6>3 `� CITYIZIP L <br />i <br />m <br />RO <br />p <br />CROSS STREET Qi APN I p7a 03o0R PARCEL SIZE • O O L LAND USE A�PJ�PLICATION # <br />D <br />OWNER NAME GC, PHONE <br />rn <br />OWNER ADDRESS r� G_ CITY/STATE/ZIP <br />CONTRACTOR ��V r/��JC(iV1 t S V✓ C Cwt//� ��Js� In 4:7r PHONE <br />CONTRACTOR ADDRESS /N l ! L C�ii� /LCI C2� V CITY/STATEIZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS ' I CITY/SSTTAITE%/ZZIIP <br />LICENSE )5-C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) El Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE gDomestic/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 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />U New <br />❑ Raise Well <br /># of borings <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 Schad ❑ Steel ❑ Plastic D Stainless Steel D Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack m/x17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />DEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP_J Pump Set ft Standing Water Level If <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 />NII\INIL V bl Hot R ADVA\CF NOTICE RFQCIRED FOR INSPECTIONS - PLEASE ( ALL (2119) 953-7697 <br />7DEPARTMENT USE ONLY <br />Application Accepted By C__/—� Z -L Date / .? <br />Grout Inspection By Date /I <br />Pump Inspection By Date l� <br />Soil Boring Inspection By Date <br />COMMENTS line:JYv,&yi r1n-0r(I11Y1c,3PS-64�'vJeII M9 <br />Area L Employee ID# iC91� K <br />11 SPECIAL Well Permit <br />11 WAIVER Received Aq <br />Co structed Well Depth <br />• o q SSI � iZ l � 2 6zr �c,, l <br />PE Sc Received <br />Codes Info B Cash <br />Amount Date Permit/ <br />Remitted Service a uest# <br />Invoice #6'% <br />O <br />II <br />3&'1 WS -07 <br />RO <br />p <br />Cp <br />T'� <br />NT <br />EHD043-06 10/25!2021 Page 1 of2 Well/Pump Permit <br />