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r WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT^^ <br />ALL 1U9 953-7697 FOR INSPECTIONS <br />EXPIRES(( 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />� �B'l 00 <br />CA 'Z r' � .• r y 9 r CITY/ZIP <br />L—u [ �U !l� <br />2 ..i '% <br />CROSS STREET <br />7;ck_ jnn� <br />_ <br />1� +; I•f APN OS I � Vv'2_7 PARCEL SIZE i <br />i <br />LAND USE APPLICATION # <br />OWNER NAME <br />� n `%uant <br />ut.n �Gi=C 4 L;:(,- s Mt—�-C'F <br />PHONE �0q <br />'- -71, <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />%�,tJr�e'�v,�4, w <br />`/'.S2 j <br />CONTRACTOR <br />L" �lr„-f<..%'sdc�_/ <br />r/ <br />'A <br />PHONE C(,l(, <br />7) I 'LY3V <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />Nell� ; z, .w <br />�¢� (A 9S_6r� <br />SUBCONTRACTOR Ntl DiiUinE L"+'Oan f PHONE 9db Zf _j 7 7 <br />SUBCONTRACTOR ADDRESS J (; <% I� 'f�rl2 ' N_[.c.:'f CITY/STATE/ZIP Sc.­+ttnnen+, , CA ? 1-9.Z �- <br />r <br />LICENSE 54C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER % U C � � � EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: I : General Mineral/Coliform Bacteria (4391) [.1 Dibromochloropropane (4392) 1L 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 ;KGeotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u slew rump u rump 1-meplacemeni u rump Kepalr u Kalse vven uasmg <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth2,0 ft Excavation L in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />in <br />Grout Seal Depth 'L✓ ft Neat Cement (94 /b 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 ❑ Submersible❑ 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By C &,, o Date ����' f' -Z ❑ SPECIAL Well IAt, <br />Pump Inspection By Date 11 WAIVER I i^^i' ` 1, <br />Soil Boring Inspection By Date Constructed Well Depth <br />y� ft <br />COMMENTS APb _ <br />_� <br />N <br />M <br />D <br />0 <br />O <br />m <br />m <br />N <br />�-- 1111L <br />Amount <br />Remitted �' /. • • <br />7'�//�V <br />(`, .//,fir-/■ <br />EHD043-06 04/07/2022 Page 1 of 2 Well / Pump Permit <br />