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I% WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMII <br />i <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNERADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS lam./C <br />GALL (ZUV) 9bJ-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />1 LZ1V/(,(--' / CITY/ZIP L/4(/( 4?K: I VZ 1 % ✓rte//4 <br />APN O M 43 00 / PARCEL SIZE 1, D b LAND USE APPLICATION # %� J <br />PHONE �9- �J / / 7 <br />7 <br />CITY/STATE/ZIP ( rx <br />(� CITYISTATE/ZIPti�b`d+ <br />SUBCONTRACTOR __ Ac 0(A PHONE; -'N44 <br />SUBCONTRACTOR ADDRESS '/7 C7y/1TATE/ZIP <br />LICENSE [A C-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION <br />DOMESTIC WELL SP MPLING: ❑ General Mineral/Coliform Bacteria (4391) 0 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 -Of -Service ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Puma / 5i' PumD Replacement ❑ PumD ReDair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D 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 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal DDimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP X Submersible❑ Turbine ❑ Other HP -_:d— Pump Set / ` V ft Standing Water Level __7 LL_ 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 />LNHNIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY p� <br />Application Accepted By �L Date Ll q §s Area Employee ID# <br />Grout Inspection By Date lJ SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS Dc�CtJYN Ca3{C�IYIGi�Cs fi� t.relj St02,J "�Z(, Z��S-(. <br />PE SC Received <a Amount Date Permit/ Invoice # Well ID# <br />Codes Info B ash Remitted Service Request # <br />3,91 oso •1 • z u <br />E14DO43-06 10/25/2021 Page i of 2 Well / Pwnp Permit <br />LA <br />i <br />D <br />0 <br />0 <br />m <br />Cn <br />6 <br />