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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-REFUNDABLE <br />({�PE,ARMIT CALL !Uy y5S-/by/ FOR INSPECTIONS tAF'IMtb "I TEAR <br />1 FROM UATE ISSUED <br />JOB ADDRESS // Z4 19 2 -r94NI (v0 2 /L -b �CITY/ZIP d rPCAC%D� / rLQ6 <br />ti <br />CROSS STREET (T�q.yN E/��///✓% LAPN 17Y-2 YD -1b P —yoo PARCEL SIZE 1-5 <br />LAND USE APPLICATION # <br />OWNER NAME SA'N Jplfa�:^� Co./Nt� 010r—IGF 49F eJPdC-, V—*' PHONE <br />OWNER ADDRESS AP OD1>1 7_4 0?0 CITY/STATE/ZIP <br />C <br />CONTRACTOR 46"q i, + 14 t, 4%jOG I4} %6,) PHONE( /J7Z—/Yh Q <br />CONTRACTOR ADDRESS <br />/3Q re IA,110V 1,0J4✓ 40'10 CITY/STATE/ZIP �' f'+L L�% /r67/ <br />SUBCONTRACTOR {/ O Dnly`«(. y %,,PHONE �Z/oA� Y6 qJ 9! <br />SUBCONTRACTOR ADDRESS ��//S-?et- 4GkHc�n fr D/Z CITY/STATE/ZIP V q , �� (/7 6l2i <br />LICENSE XC -57 C-61 D-09 Other <br />NUMBER 72699Dl'l EXPIRATION DATE V?O/2:l <br />T� <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) LI Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private i Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X 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 Li Replacement Well Well Alteration/Modification C! 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 11 Cross -Connection Repair <br />I_i INew t­-ump i Fump Ne lacemem t-ump me air i . masse vvell k-asin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary C! Air Rotary /Auger II Cable Tool Push Point Other <br />Proposed Well Depth 7_ft Excavation _6 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 1 Stainless Steel Other <br />Grout Seal Depth 3a ft ?( Neat Cement (94 /b bag/5-10 gal water) Sand Cement�y r <br />'-_ Bentonite (20% solids) G Other <br />FOMENT <br />Grout Placement Method C Pumped XFree Fall (Other TRG MI b l O --, Retardant / Accelerator (name) <br />_FMC —EIVED- <br />PEDESTAL Installed By Driller ❑ Pump Contractor - Other <br />❑ Concrete Pedestal i Dimensions: Width it Length ft Thick <br />in ❑ Christy Box Stove Pipe <br />PUMP ❑ Submersible Turbine Other HP Pump Set ft Standing Water FL4'ljRONMENTA{ <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the fol owing I <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 />IIOUR ADVANCE NOT] o; REQUIRED FOR INSPE i IONS - PLEASE CALL (2 ;953-769' <br />/ DEPARTMENT USE ONLY <br />Application Accepted By /L-��L Date a7 a a <br />Grout Inspection By <br />Date <br />Pump Inspection By Date I <br />Soil Boring Inspection By Date 4 V` <br />COMMENTS <br />18/ <br />Area 1 stDek4-r Employee ID# / ' <br />1 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />..I <br />M <br />g <br />A <br />M <br />N <br />to <br />PE SC Received Check#/ <br />Codes Info A By e Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted I Serviceuest # <br />936 D &54 <br />EtfD043-06 04/07/2022 r 2 / f 1 C Q / 2 Page I of 2 " Well / Pump Permit <br />