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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 PERMIT <br />G�A <br />(ZUU) 953-7697 FOR INSPECTIONS EXPIRE5 1 YEAR FROM DATE ISSUED <br />��� <br />JOB ADDRESS &6," Ayy4,n /1eOe�.GC <br />%LL <br />CITY/ZIP <br />CROSS STREET /� Ot�1X APN ;&96- <br />/�� <br />IiJ(7 —050-a)0 PARCEL SIZE/(;-`; o -LAND USE APPLICATION # -A111/ <br />OWNER NAME .�.7CGa l/r�.7•'u�C <br />�c jl <br />�� S�J <br />PHONE 6:2 2825 - 5?�0 <br />OWNER ADDRESS � w C-w/S¢ /-fv¢y <br />u¢ <br />CITY/STATE/ZIP /�GunT¢Gp� L 9$33 <br />3 <br />CONTRACTOR 202 <br />tom <br />PHONE <br />✓` <br />ADDRESS <br />7g.,II <br />C).tC <br />y4Gu7�CONTRACTOR <br />2 <br />SUBCONTRACTOR I,, — /w T <br />i�iS5""ej-s <br />PHONE I9/(,�_1�2lqr <br />/�- / <br />SUBCONTRACTOR ADDRESS '7059L�S/.�-�c� <br />�tl.!�Bycr G <br />r+7 <br />CITY/STATE/ZIP l �� � c7 ,/C, 9 I <br />L/C -57 Ll57 I C-61 ❑ D-09 <br />❑ Other <br />/75Cl <br />NUMBER i' �J EXPIRATION DATE t Ax)/�3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE 1 Domestic/Private ❑ Irrigation/Agricultural C:: Industrial I l Water Quality Monitoring V 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 Replacement Well ❑ Well Alteration/Modification Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings V Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />_ u New rump _ rump Kepiacement u rump Kepair Kaise vveii Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary Air Rotary I I Auger L Cable Tool `/ Push Point iL Other <br />Proposed Well Depth >0 ft Excavation in diameter Open Bottom I- Gravel Pack/Gravel Size in diameter) <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness Gauge/ASTM Sched Steel L' Plastic Stainless Steel L1 Other <br />Grout Seal Depth `_ .-� ft Y Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement PA40EUR sack mix17 gal water <br />R -A 17 <br />Bentonite (20% solids) [.1 Other 4; <br />Grout Placement Method -- Pumped 5 Free Fall v, Otherfi-.,1- 5go Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller II Pump Contractor ❑ Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick - <br />in i Christy Box C Stove Pipe tin At <br />PUMP I I Submersible Turbine LI Other_ HP Pump Set ft H§Jpr V Nllou I ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the fo *%litems: 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 />11ININI L M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE_ONLY <br />Application Accepted By t �� Date '9 / Z Area (L L� Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />❑ WAIVER Received <br />Date 2 2 1--t `' structed Well Depth <br />ft <br />T <br />PE SC Received Check#/ Amount ate Permit/ <br />Codes Info C h Re itted S rvice Request # <br />Invoice # Well ID# <br />kid <br />EHDO43-0604/07/2022 Page I of _ Well / Pump Permit <br />