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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 209 953-7697FQR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS h-. CITY/ZIP <br /> M <br /> �/ D <br /> CROSS STREET ().5 '- `�jt( IZ.N�JlI'E° APN O 02PARCEL SIZE LAND USE APPLICATION#�( o <br /> M <br /> PHONE <br /> OWNER NAME �' �,`• / �� �-' Z[ / v <br /> L/ `" m <br /> l� <br /> OWNER ADDRESS /�/1°L' nn CITYISTATE/ZIP <br /> CONTRACTOR /�a�+.S J Q `� PHONE "�)�-�G 1 Ti < 2, � <br /> CONTRACTOR ADDRESS PO L��)v CITY/STATE/ZIP <br /> SUBCONTRACTOR �/ «I�✓( C t�"!/J PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT�E7/�ZIP / ll <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 3�/ . — EXPIRATION DATE 6— L-_,$ <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 X-New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) Aiiiiiiiiiiiii AIIIIIIIIIII #Of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service ewa <br /> New Pump ❑ Pump Replacement ❑ Pump Repair A NisWD <br /> WELL CONSTRUCTION <br /> Drilling Metho�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other // <br /> Proposed Well Depth 20 ft Excavation _ in diameter ❑ Open Bottom %e Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Udall Cssing Diameter in Thickness/Gauge/ASTM Sched Z-0 ❑ Steel,XL Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 7 ft ❑ Neat Cement(94 lb bag/5-10 gal water) >eSand Cement lo, 3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other PMME <br /> Grout Placement Method)<Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:WidthL� ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe f <br /> PUMP ubmersible❑ Turbine ❑ Other HPmm <br /> Pump Set ft Standing WJWA4GLAQU1N C <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect tothe fo -W <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> C� <br /> Application Accepted By L� Date 10 —0/a4;? Area Employee ID# <br /> Grout Inspection By Date 7 ❑ SPECIAL Well Permit <br /> Pump Inspection By N Date V ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Na' 31.7 q <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A AY Cash Remitted S rvice Request# <br /> La?D 05► is 3 <br /> SD << <br /> 3Ga �o ti <br /> tt <br /> EHD043-06 04/07/2022 Page 1 01`2 Well/Pump Permit <br />