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I 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />J <br />PERMIT <br />9 �f CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 01 D / CJ U �::) - <br />CROSS STREET J f'r'G 11 <br />OWNER NAME <br />OWNER ADDRESS c�YD ! p Q <br />CONTRACTOR // /OU�/{1GZ. <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CITY/ZIP <br />APN d 3 J a as 0e PARCEL SIZE a'(I a LAND USE APPLICATION # 1 <br />Ike-, PHONE /o - /C� �o 9" �7 v <br />I / c/Y��� T r CITY/STATE/ZIP AIII %- <br />L/ <br />L `1533 7 <br />air �►" suer 1 y IE- PHONE ao9- 93/-3a/n <br />SUBCONTRACTOR ADDRESS / Y r / I <br />LICENSE 4 C-57 ❑ C-61 Cl D-09 ❑ Other <br />CITY/STATE/ZIP <br />PHONE <br />%C ITTYISS/TAA/TlE/ZI P <br />NUMBER ffr%/i n I & EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ MonitoringWell(s) #of wells ❑ SoilBoring(s) #of borings ❑ Geotechnical #of borings <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump AL Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib 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 ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ 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 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 />NIIyilli �1 24 fl01_R kl)VANCE \01I( E REQC iRED I -OR INSPECTIONS - PLE_ %SF ( ki-L (209) 953-7,69- <br />DEPARTMENT USE ONLY <br />Application Accepted By 'Z—Lr/ .3% Date �7;? <br />Grout Inspection By <br />Pump Inspection By <br />c <br />Soil Boring Inspection By <br />COMMENTS D of (,, +9N, <br />Date <br />Area 3 Employee ID# <br />❑ SPECIAL Well Permit <br />Date 21J ��aC3�2.0`Z—�-- ❑ WAIVER ReceiveoA <br />Date Constructed Well Depth <br />1 n 11 f 1-,0 1G1� 1-) C I I AI '`C A <br />ft <br />N <br />m <br />D <br />0 <br />0 <br />m <br />m <br />rn <br />fn <br />PE <br />Codes <br />SC Received Ch Amount Permit/ <br />Permit/ <br />Info B Cash Remitted Da Service Re uest # <br />Inv <br />9D# <br />C <br />1 <br />`7-13% 0 a 3 ZZ <br />y /Ro <br />q <br />co <br />T�� <br />NT <br />EHD043-06 IOP_5/2021 Page I of 2 Well / Pump Permit <br />