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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 />OB ADDRESS <br />PERMIT CALL 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS < -I S OGZ �* CITY21P g 6 <br />CROSS STREET C �oyu" 1�G� APN I CI �CIa� PARCEL SIZE t <br />_LAND USE APPLICATION # / <br />OWNER NAME // D Q cPHONE/ l�-a�- ��J?F- /� <br />OWNER ADDRESS ! ! /� O CITYISTATEIZIP Sk6& C✓`7"- �Sa 6�, <br />CONTRACTOR ZVI a <br />DPHONEO 1� L <br />CONTRACTOR ADDRESS CnY/STATE21P 511)6`V}1 /Jf /C/ v <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS C(n�Y/STATE21P <br />LICENSE y�C-57 =l C-61 D-09 Other NUMBER L �(Y /� EXPIRATION DATE 3i /o�� <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE I-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) 4 of borings 1-1 Geotechnical <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pum2 Pump Replacement ❑ Pump Re air❑Raise Well Ci1/0, <br />WELL CONSTRUCTION asn <br />Drilling Method 7 Mud Rotary ❑ Air Rotary Auger Cable Tool L Push Point 11Other F ROU/N 24 1 <br />Proposed Well Depth ft Excavation in diameter _i Open Bottom = Gravel Pack/Gravel Siz D N <br />= Conductor Casing in diameter / Conductor Casing Depth ft Ar Iometer <br />Well Casing Diameter in Thickness/Gauge/ASTM a/ASTM Sched EMi <br />— 9 '; Steel =Plastic _] Stainless Steel Ci Other <br />Grout Seal Depth ft D Neat Cement (941b bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) 11 Other <br />sack mix/7 gal water <br />Grout Placement Method Pumped - Free Fall _ Other Retardant / Accelerator (name) <br />Installed By Driller ❑ Pump Contractor <br />Concrete Pedestal ❑Dimensions: Width ft <br />Christy Box = Stove Pine <br />Other <br />Length it Thick <br />cUMP IV Submersible - Turbine ❑ Other HP ' Z 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 />NIININILrNI 24 HOL R ADN*ANCE NOTR(F RTQCIRED POR 1 ,S1'I:(:I'IONS - PLE:1SE CALL. (2(M)) 9_53 -769 - <br />DEI ARTMENT USE ONLY <br />Application Accepted By Date Area (>/IAL <br />Employee ID#Grout Inspection By : e❑ SPEWell Permit <br />Pump Inspection By �f <br />-x ?L Date i WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />'VC- I� Amount Date I Permit) <br />Codes Info By ��,astr RemittedService Regl <br />Constructed Well Depth <br /># I Invoice # <br />Well ION <br />EHDO43-0604/072022 Page 1 oft <br />Nell / Pump Pemtit <br />ft <br />_T <br />D <br />v <br />0 <br />M <br />M <br />rn <br />