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h <br />M <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Ivuly-rctt-UNUABLt rhRMfr GALL ZUy U04-fbUt FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �j'7 CITY/ZIP <br />CROSS STREET �() APN Op / l PARCEL SIZE • I LAND USE APPLICATION # <br />OWNER NAME n v 90 -a -6-51b f <br />PHONE <br />OWNER ADDRESS I 2 Q nro <br />CITY/STATE/ZIP / <br />CONTRACTOR 1 1 PHONEwgaRt _:�4l/ <br />�! <br />CONTRACTOR ADDRESS t CITY/STATEIZIP r P <br />SUBCONTRACTOR /' /�_ PHONE - <br />SUBCONTRACTOR ADDRESS TY/STATE/ZIP <br />LICENSE i C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: r! General Mineral/Cnlifnrrn RartPrin (4391) rl nihrmmnchlnrnnrnnanP (d3Q91 n Arsanit- (d3Q31 <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 Borings) # 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 Method D 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 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 ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Y Submersible❑ Turbine ❑ Other HP ___L_ Pump Set /0(/ ft Standing Water Level ft <br />Plot Plan Re uirements: 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 />�IININIt v1 24 H0117:.1DN'.%SC E. AY)"FI('E REQ( IREID Ft Of, INSPE.C7IONS - I'LEASE ( kLI. (209) 95;-71697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z_ Z__ Date 6 3 <br />Grout Inspection By Date <br />Pump Inspection By Date 1-12 Y1 <br />Soil Boring Inspection By Date <br />COMMENTS Do��,,,oen C a�irr/ifrac S 6� vie �_ <br />Area o` Employee ID# Fte^nk <br />0 SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth IJA, __ ft <br />—(t 1., Zit,�j I <br />Ln <br />D <br />v <br />0 <br />m <br />ur <br />PE SC Received Chec <br />Codes Info B ash <br />Amount <br />Remitted <br />a te Permit/ <br />Service Request # <br />Invoice N f <br />/ <br />WellID# <br />Agn <br />9391 <br />A -7 7 <br />OM3 47,WF004339F <br />JOA <br />wv <br />M VIRO <br />CDU <br />E <br />AC <br />CHD043-06 10/252021 Page I of 2 Well I Pump Permit <br />