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oma25050\ <br />1 ' _ WELL/PUMP PERMIT <br />;SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDAB/ILE PERM`I•T/ UALL (ZUU) V0J-/bV1 FOR INSPECTIONS ! 1tXPIKtb 1 YEAR FROM UATE ISSUED <br />JOB ADDRESSu(� S W • Q0.1•�C r SI' II CITY/ZIP <br />CROSS STREET Ty1orf�� 1pTSI APN CSS *20 Ob PARCEL SIZE V1 i LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />CONTRACTOR �"t 0 fhd'V1sv% 4,.J/' t 1f0 �Y•'�� thy P�HONrEPO'S61 -S-701-S-701CONTRACTOR ADDRESS I�a T�'ASTYj�, )yV/ty CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS 'S("M Z - <br />LICENSE ), C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />CITY/STATE/ZIP <br />NUMBER <br />PHONE `ftC`r- <br />bgnE <br />EXPIRATION DATE J C <br />- 31 - <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring )( 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 ❑ Replacement Well C Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings �( Geotechnical <br />❑ Out -Of -Service Well E Out -Of -Service Well Renewal C Cross -Connection Repair <br />3 # of borings <br />i i New rump i, rump Kepiacement a rump Kepair I Kalse vveu easing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary C Air Rotary DS Auger C Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth; ft Excavation 16 in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft t4 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method C Pumped C Free Fall 9 Other TYty'.tt C Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor C Other <br />❑ Concrete Pedestal CDimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft 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: 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT U E N L Y <br />Application Accepted By`yE g h Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By SE Date <br />COMMENTS <br />Area b'7 <br />C Employee ID#�,-1 cc <br />C SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # <br />Codes Info By Cash Remitted Service Re uest # <br />Well ID# <br />Z <br />I <br />' rNVIRON <br />ITAL HEALTH <br />PEW,' <br />FNICES <br />EHD043-06 04/07/2022 Ngc I ot-' Well / Pump Permit <br />