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I 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 />.JOB ADDRESS <br />CROSS STREET— <br />OWNER NAME T= <br />OWNER ADDRESS C�PC)?D� <br />CONTRACTOR <br />CONTRACTOR ADDI <br />IF`I/Aw <br />N <br />T697 FOR INSPECTIONS ,,EXPIRES 1 YEAR FROM DATE ISSUED <br />C <br />PARCEL SIZE S LAND USE APPLICATION # <br />PHONE t2D /A ` 733 177,?_ <br />CITY/STATE/ZIP'S i 2 <br />PHONE ,/ <br />CrrYISTATE/ZIP I� (14 CJ�lS 1_ <br />SUBCONTRACTOR PHON <br />SUBCONTRACTOR ADDRESS _ QfrYISTATE/ZIP <br />LICENSE ;%)C-57 H C-61 Ll D-09 F. Other. <br />NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) DlbromochlorODroDane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private LIrrigation/Agricultural [ I Industrial I I Water Quality Monitoring C Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner' Water System Name Contact Name or Phone Number <br />TYPE OF WORK I New Well L Replacement Well E Well Alteration/Modification U Other <br />DEPARTMENT USE ONLY <br />1 Date l v <br />I.' Monitoring Well(s) # of wells E Soil Boring(,) t of borings I I Geotechnical <br /># of borings <br />I Out -Of -Service Well C Out -Of -Service Well Renewal Il Cross -Connection Repair <br />Date <br />I New Pum Lpump Replacement C Pump Repair I I Raise Well Casing <br />Pump Inspection By <br />WELL CONSTRUCTION <br />DateVI& lr <br />Drilling Method I Mud Rotary I Air Rotary f 1 Auger 1"1 Cable Tool I i Push Point I I Other <br />Soil Boring Inspection By <br />Proposed Well Depth ft Excavation in diameter I1 Open Bottom r Gravel Pack/Gravel <br />SizenAi ter <br />I Conductor Casing in diameter / Conductor Casing Depth tt <br />COMMENTS <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Il Plastic [I Stainless Steel <br />r1 ORECEIVED <br />Grout Seal Depth it L Neat Cement (94 Ib bag/5-10 gal water) I1 Sand Cement <br />sack mix/7 gal water <br />I : Bentonite (20% solids) I. Other <br />MAY 0 i 2022 <br />Grout Placement Method I I Pumped 1. Free Fall L_ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I_I Driller C Pump Contractor I I Other NVIRONMENTAL <br />I: Concrete Pedestal /:/Dimensions: Width it Length ft Thick HEALTH DEPARTMEN <br />�in 1-. Christy Box i-. Stove Pipe <br />PUMP 4.Submersible❑ Turbine E 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 />MINIA11UNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CAU (209) 953-769; <br />Application Accepted By—� <br />DEPARTMENT USE ONLY <br />1 Date l v <br />Area Employee ID#t <br />Grout Inspection By <br />x-)38) <br />Date <br />] SPECIAL Well Permit <br />Pump Inspection By <br />)y� /"� <br />DateVI& lr <br />:1 WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth ft <br />COMMENTS <br />U) <br />m <br />m <br />m <br />ra <br />fi <br />PE <br />Codes <br />SC Received <br />Info y <br />Check#/ Amount <br />Cash Remitted <br />at Permit/ Invoice # Well ID# <br />Service Request # <br />x-)38) <br />0�o <br />v UL <br />J1! (`l_1u3�L' <br />EHD(A3-061()/:5/2021 Page 1 ur 2 Well /Pump P-mlit <br />