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Z <br />4 <br />l <br />. 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />2,20;t Veor 11'1 jfoc PbnC t CITY/ZIP 95215 <br />VV411''r 1106 APN 1010019 977 PARCEL SIZE9,31 LAND USE �jAPPLICATION <br />��# <br />`tea IVadOr D�ra� / y4011 120141 PHONE 61) �If7/ 68so <br />a3 - b �-, v Itie Site CITY/STATE/ZIP '5 fa r ti'% /11 x/5710 <br />ADDRESS y5�/ l Z F= we he#- A✓ C <br />TRACTOR <br />PHONE I-> <br />CITY/STATE/ZIP '1 4 rk kilil (14 f5 -2N - <br />SUBCONTRACTOR <br />5-2N - <br />SUBCONTRACTOR ADDRESS CITY/STATE/; <br />LICENSE ❑ C-57 X C-61 ❑ D-09 ❑ Other NUMBER. <br />PHONE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE X Domestic/Private ri 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 />17 Out -Of -Service Well ❑ Out -Of -Service Well Renewal -I Cross -Connection Repair <br />Y -New Pump ❑ rump Keplacement u t-ump Kepair a Kalse well casing <br />WELL CONSTRUCTION <br />Drilling Method I 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 __,f ft Length _ ft Thick C <br />in ❑ ChristyBox ❑ Stove Pipe <br />PUMP V Submersible El Turbine ❑ Other HP Pump Set / YO L 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 />MINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />ll llDEPARTMENT USE ONLY <br />Application Accepted By �!/y Date `i �F �� Area (' Employee ID# Ff it Pik, <br />Grout Inspection By /- Date ,,,�/ ❑ SPECIAL Well Permit <br />Pump Inspection By fit- •SCJ %F.evlkc }� Date �z lT2 ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS We -11 ne <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Permit/ <br />Remitted ate Service Re ues Invoice # <br />1514 <br />8 <br />J <br />h Oly OUN <br />It <br />PM <br />EHDO43-06 10/25/2021 AV�t : H L Q1 Hage I oft Well / Pump Permit <br />