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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />SC Received <br />Info B--c—as-15—Remitted <br />CALL 209 953-7697 FOR INSPECTIONS 1 YEAR FROMDATE ISSUED <br />.JOB ADDRESS <br />/ <br />Ail e <br />LEXPIRES <br />CITY/ZIP SA*e4h� e4 <br />CROSS STREET 70a/i <br />APN ' <br />r� <br />13 0 �� PARCEL SIZE 14a LAND USE APPLICATION # <br />OWNER NAME ( � <br />Q ,VQ�.�� <br />PHONE 2699F .3g6 -- <br />OWNER ADDRESS 2303 <br />Aoe <br />CITY/STATE/ZIP 6 f�� 1e1AJ Lla gS zo3 <br />CONTRACTOR 344 <br />PHONE 74 J 77Z- Z 71'-7 <br />CONTRACTOR ADDRESS f/' <br />CITY/STATE/ZIP �lZ�/1Co/ �,�r���s fir► 5s21� <br />0 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 <br />D-09 <br />Other <br />NUMBER ZQZ 7D70 EXPIRATION DATE' 3/ -ZO Z Z <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ADomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Contact Name qr <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnic I <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair's 1 <br />New Nump ^ Nump Replacement Num <br />Raise Well <br />WELL CONSTRUCTION EO V COVN7y <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other HEALTH nPR4SNTAL <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size NT in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft 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 Pumped Free Fall Other i Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 Driller 1 Pump Contractor Other <br />E Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in I Christy Box Stove Pipe <br />PUMP 74 Submersibles Turbine Other HPPump Set /Lr- ft Standing Water Level 'V7 ft <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 US ONLY <br />Application Accepted By G L— Date <br />Grout Inspection By Date n� <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS /A W - �1 <br />Date <br />Area I I —1 Employee ID#�V <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info B--c—as-15—Remitted <br />Check#/) Amount Date <br />i i <br />Permit/ Invoice # Well ID# <br />Service Request # <br />81 <br />3215 <br />_057<) <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />