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/-•vl :s C4G� <br /> 1 ,:: • ► WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS z 1 CITY/ZIP ` <br /> m <br /> CROSS STREET t,&J d pVPIs t X11 APN 076� PARCEL SIZE_LAND USE APPLICATION# o <br /> [/ / q(� ;0OWNER NAME C//^ t� / �/� OL PHONE ` [ " N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTORCJ/'�asai^ �V– PHONE .32W"d Lx L <br /> CONTRACTOR ADDRESS L �v y� CITY/STATE/ZIPrZt� <br /> SUBCONTRACTOR /C)6 «I� CG' 6m), ' PHONE �/�✓ "—Z i <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 El D-09 E) Other NUMBER :31/ 23&-f EXPIRATION DATE 6" 22- <br /> DOMESTIC WELL SAMPLING:XGeneral 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 >11LNeW 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 <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 2� ft Excavation -z in diameter 11 Open Bottom >e Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched —2-400 ❑ Steel, <Plastic ❑ Stainless Steel ❑ Other__ <br /> Grout Seal Depth3 Co ft ❑ Neat Cement(94 Ib bag/5-10 gal water) >eSand Cement /0, 3 3 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 ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing WAdd`Ld *QUIN C <br /> OUNft <br /> 11 FRP*!F%MA1:$ffM <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect tothe fo dit� <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 /> MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 3J �a Area ` Employee ID# <br /> Grout Inspection By AA 6 " ?lam Date 7-7 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 6d' /03e' 2-1' -3/ 9 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A AY Cash Remitted 6 S rvice Request# <br /> L13 20 ©1�;'► IS a <br /> L436�, 0 <br /> 43ci I Sp tl <br /> 3' 4 -70 lk <br /> ,t <br /> EHD043-06 04/07/2022 Page 1 of 2 Well/Pump Permit <br />