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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENI"AL 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 v� (�), (r•.)t�bQr-D/')V-�. _- -_ CITY/ZIP m S-�v�K r, rt_ 9Sa©,3 y <br />m <br />D <br />CROSS STREET. L fnLO �h S APN 1-6-7380 1(o PARCEL SIZE 13 1 LAND USE APPPPLIC,A,TTIION# o <br />OWNER NAME O �(, ,n, -" _ _ PHONE CSC/ 1 _� m <br />OWNER ADDRESS_? L�_1/ij O CITYISTATE(ZIP <br />CONTRACTOR i atll mE' -r—s -----„--_- --- PHONE <br />CONTRACTOR ADDRESS 139 CI'1 Ar -e C3�L- PCITY/STATE/ZIPS � ,�^J S2, C -A 9 1T/"3I <br />t` vCi <br />SUBCONTRACTOR ��, -1 G- J ►{ 1 'r°t 4 `'p `V'FiF'l�,r �1 — PHONE _ I V <br />/��J <br />SUBCONTRACTOR ADDRESS it ( 3_, 5 Tr�`t� C C'� f f�/ , CITY/STATE/ZIP Ac-:^C.w-ti Cufif-[l CA <br />'11 Yt� <br />LICENSE 1�( C-$7 C-61 it D-09 Other NUMBER I D� 4� EXPIRATION DATE I !J ✓) (�p•- <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE C Domes ticlPrivale Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization —� <br />(3 Public Water System <br />If different from Owner. <br />TYPE OF WORK <br />Water System Name <br />Contact Name or Phono NOmber <br />F New Well 7 Replacement Well ❑ Well Alteration/Mod if cation Other <br />Monitoring Well(s) # of wells P Soil Boring(s) 9 of bonnph X Geotechnical c2 ° of bon -10s <br />n Out -Of -Service Well ❑ Out -Of -Service Well Renewal -1 Cross -Connection Repair A <br />rJ New Pump i Pump Replacement rI Pump Repair 1 Raise Well Casino OP._ <br />WELL CONSTRUCTION —"—T�► <br />Drilling Method !:i Mud Rotary - Air Rotary y Auger F Cable Tool Push Point ❑ Other _ <br />Proposed Well Depth 30 —ft Excavation In diameter Open Bottom r- Gravel Pack/Gravel Slze a e8r <br />Conductor Casing in diameter / Conductor Casing Depth __ft S,AN J <br />Well Casing Diameter Q in Thickness/Gauge/ASTM Sched Steel -1 Plastic Stainless Stee! D Others O9Q <br />Grout Seal Depths ftCNeat Cemen' (941b bag/5-14/ gal water) Sand Cement �� <br />Bentonite (20% solids) t7, Other pAp <br />Grout Placement Method Pumped ?�Z Free Fall Other + T £ ,” i'� �: Retaroant t Accelerator (name) <br />PEDESTAL Installed By I Driller it Pump Contractor Other --� <br />Concrete Pedestal :Dimensions. Width ft Length ft Thick <br />in r; Christy Box - Stove Pipe <br />laummt L Submersible; Turbine Other HP Pump Set If Standing Water Level it <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <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 />%IININII A Li UUl 11 VriANCE' N01 WE' RE"QVIRLD I OR IN1,11KC IONS- PLEASE CALI.(2o9t9;3.769T <br />DEPARTMENT U$E ONLY <br />Application Accepted By .G— /� �� L Date >' <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area -'t Employee 04AIL <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received C / <br />Info B Cash <br />Amount I Date <br />Remitted <br />Permit/ Invoice# WeIIID# <br />S rvico Re st # <br />.lb <br />EHM43-06 04/072022 page 1 ort <br />av 412M3i07tD <br />win r Pim;, P -n <br />Nr <br />