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1 WELUPLIMP 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 _1 <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Ae <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />l S g Il <br />et GAO -.T -r <br />SUBCONTRACTOR ADDRESS <br />GALL (LUUI UOJ-/t)`.!/ FOR INSPECTIONS l=XF'IKtb T TEAR FROM DATE ISSUED <br />7&Atk %Z CITY/ZIP 1 a V F <br />__ A/P� N �/ �nnZ Z' _ 0 D 'L- PARCEL SIZE $1 1�M1 AND USE APPLICATION # <br />YPSGI PHONE -7 <br />/�Ft7- QS9S o <br />PHONE -3-3 <br />CITY/STATE/ZIP >^)ct �n k i Cf ee r1 5 q6 <br />w,1 I J 4 !��' PHONET- �,72—r <br />CITY/STATE/ZIP <br />PHONE 3 2.7'.JC <br />LICENSE .1w,C-57 C-61 I D-09 Other <br />�jCITY/STATES///ZIP <br />NUMBER— 7,+ r EXPIRATIONDATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE i Domestic/Private igation/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 Mew Well i Replacement Well Well Alteration/Modification I Other <br />I i Monitoring Well(s) # of wells Soil Boring(s) # of borings i Geotechnical # of borings <br />`i i`Out-Of-Service Well I Out -Of -Service Well Renewal i i Cross -Connection Repair <br />>AeW Pump i Pump Replacement i Pump Repair L Raise Well Casinq <br />Drilling Method Mud Rotary 1 Air Rotary i Auger 1 1 Cable Tool I Push Point Other <br />Proposed Well Depth -_7,_<'0 ft Excavation � in diameter L Open Bottom Gravel Pack/Gravel Size in diameter <br />Conduct Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diamete 1n Thickness/Gauge/ASTM Sched ��_ Steel elastic Stainless feel Other <br />Grout Seal Dept[ �f ft i Neat Cement (94 Ib bag/5-10 gal water) Vand Cement /V y sack mix/7 gal water <br />Bentoriite (20% solids) Other nw MENT <br />Grout Placement Method .dumped Free Fall Other :_ Retardant / Accelerator (name) <br />PEDESTAL Installed By J`Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width _/ ft Length ft Thick a <br />in Christy Box Stove Pipe AN 19 <br />PUMP XSubmersible Turbine Other HP IJ Pump Set ft StandinSANtK*QWIN COUNTYft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the AN EMPS <br />IT <br />Coordinates, property tines, adjoining properties, water bodies or courses, drainage pattern, roads, e, we s, s ructures, <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 />NIININIUNI 24 HOUR kDVANC E. NOTICE REQUIRED FOR INSPECTIONS - PLEASE: CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z ' Date , �� Area Employee ID# J <br />Grout Inspection By ate ❑ SPECIAL Well Permit <br />Pump Inspection By Date 7,1 el ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />Ql 1z 1,,51 <br />ft <br />N <br />mm <br />D <br />a <br />M <br />m <br />N <br />to <br />PE <br />Codes <br />SC Received <br />Info Ay <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />5prvice Request # <br />hO <br />ds 1 <br />50 S s 3 <br />® 70il ZZ <br />L130 <br />1X0 <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Permit <br />