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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 />IVUIV-rCEFUNUABLE rF_RMI I IUALL LUtIyb3-!by! FOR INSPECTIONS i tXF'IKt%b�11 YEAR FROM UATE ISSUED <br />JOB ADDRESS � ( _ /� F �I1 CITY/ZIP r <br />CROSS STREET APN _ Q Z �� �ARCEL SIZE �A-AND USE APPLICATION # <br />OWNER NAME �J <br />OWNER ADDRESS <br />D— <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE A C-57 ❑ C-61 ❑ D-09 ❑ Other <br />/n'P//H�ONNEr /, <br />CITY/STATE/ZIP l..�t�C/ /��b-CJ" , <br />PHONE [-� Q� �GJ'�� `/ � <br />CITY/STATE/ZIP I /� -/ 5'; cs <br />PHONE ' <br />97/STATE/ZIP <br />NUMBER �1 v ! EXPIRATION DATE - <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ 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 Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair A <br />❑ New Pum Pum Replacement El Pump Repair :1 Raise Well Casin /'�4 <br />WELL CONSTRUCTION <br />Drilling Method El Mud Rotary El Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other y <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size Wfftel <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft ✓ U JJ <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 s <br />❑ Bentonite (20% solids) ❑ Other Fpgp, <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 Pine <br />PUMP]Submersible❑ Turbine 11 Other HP LL Pump Set o1 l () ft Standing Water Level _ C?J 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 />�NIINTl11t11 24 HOCiR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />1 <br />RTMENT U E O LY Q _17>Application Accepted By ' Date �- Z Area (� Employee ID# <br />Grout Inspection B Date ❑ SPECIAL Well Permit <br />Pump Inspection By t, Date ��.�f.1. ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS ��, t -cd p. �ns/t•Y•. COirntci- �4�/1itL <br />PE SC ReceivedChec Amount Date Permit/ Invoice # Well ID# <br />Codes Info B ash Remitted Service Request # <br />L 0 <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />Ln <br />1 <br />m <br />0 <br />0 <br />m <br />m <br />m <br />