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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 />NON-REFUNDABLE PERMIT CALL (2091 953-7697 FOR INSPECTIONS EXPIRES 1 YFOR FRAM nATF IRAI IFrt <br />.JOB ADDRESSCITY/ZIP ' ` <br />CROSS STREET APN T � Y_PARCEL SIZE,/- 71 -AND USE APPLICATION # <br />OWNER NAME 2 O �� PHONE ,20- 679-1 13 <br />OWNER ADDRESS 3� V1n Pd CITY/STATE/ZIP&-y r.AJ zQn//'� <br />CONTRACTOR Y PHONE Lg155 /t��r�(_/` <br />CONTRACTOR ADDRESS CrrY/STATE/ZIP'Op(� ✓ - / ��LJ <br />SUBCONTRACTORQ PHONNIE�/ 1�Q <br />SUBCONTRACTOR ADDRESS -/a&JCITY/STATE/ZIP—ft f/l/V L . L/� J <br />LICENSE C-57 I I C-61 I I D-09 Other NUMBER- 410?vu EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE C Domestic/Private Irrigation/Agricultural P Industrial I I Water Quality Monitoring L' Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well C Replacement Well I-, Well Alteration/Modification ❑ Other <br />E Monitoring Well(s) # of wells I Soil Boring(s) # of borings Ll Geotechnical # of borings <br />C Out -Of -Service Well F Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump Pump Replacement I Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling MethodMud Rotary I Air Rotary I 1 Auger 11 Cable Tool 11 Push Point I 1 Other <br />Proposed Well epth ft Excavation 1, in diameter I I Open Bottom �t' Gravel Pack/Gravel Size B 't (*tfn diameter <br />C Conductor Casing _ in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched ' OC W 11Steel �: Plastic 17 Stainless Steel Ci Other <br />Grout Seal Depth 5 ft C Neat Cement (94 Ib bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method 'Pumped f: Free Fall 1. Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller Pump Contractor 0 Other <br />I : Concrete Pedestal I IDi ensions: Width _ ft Length _ t' _ ft Thick <br />in C Christy Box i, Stove Pipe DEC 0 <br />PUMP VSubmersible f I Turbine F Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followifir—i 1190 <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing weIW,4q*nbffW <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 />NIIN1Nlt'\( 24 If()( R ADN' XNCE NO TI('IC W-01'IRF.D 1011 INSI'E(TION5 - PI.LNsF C U,1 (209)453-7647 <br />DEPARTMENT U E..ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By 42 40P Date .74ee22 <br />Soil Boring Inspection By <br />COMMENTS Glf <br />ftrF' <br />Date <br />c <br />Area % Employee ID# ' N-7eg <br />I SPECIAL Well Permit <br />.1 WAIVER Received <br />Constructed Well Depth X2.3 It <br />W <br />m <br />g <br />0 <br />m <br />m <br />CA <br />w <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount D to Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />q30 <br />/IFC <br />b 1 20 <br />o !S Z <br />EHD043-0(, 101:5/2021 Page I ut 2 Well / Puvm PLmlit <br />