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1 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NLA4-KEFUNDABLE PERMIT t:ALL LUUVO4-tbUt FOR INSPECTIONS <br />INSPECTIIONS LfA,hI�KLLb) I YEAR/ FROM D <br />ATE ISSUED <br />( <br />JOB ADDRESS c O C1© o (;'SA ITY/ZIP <br />CROSS STREET aP'W {r /APN3O-'7/PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME QttS af�, /a4c�rO_M PHONE %y 7 J' -y <br />�_? <br />OWNER ADDRESS J&j-4 C <br />CONTRACTOR 7';"Z_ f (O L-A' p ✓��y11��rC <br />CONTRACTOR ADDRESS 5-( (2 4 1.)(!✓ L '�// <br />-e'- / ' "� <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 ?-(C-61 ❑ D-09 ❑ Other, <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP S 10 <br />PHONE <br />CITY/S TAT E/ZI P <br />% <br />NUMBER / O EXPIRATION DATE <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: <br />Water System Name <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings <br />Contact Name or Phone <br />❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair d//r <br />'!'.New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing "V / 0 .7n? <br />WELL CONSTRUCTION AIV JOgQU/N <br />�aT„ <br />� <br />Drilling Method El Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E�/R COU <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Iz D A diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft "fir <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ 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 />15'Concrete Pedestal ❑Dimensions: Width 6' ' ft Length ft Thick l <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP �_ Pump Set 220 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �- f� y� Date ��/�/ �'y Area ( Employee ID# �^ <br />Grout Inspection By ❑ SPECIAL Well Permit <br />Pump Inspection By7;1 / Date El <br />Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS j9pyJ u dl Pooy3g4R <br />U) <br />PE <br />Codes <br />Sc Received <br />Info By <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />C sh Remitted Service Request # <br />3$v <br />EHD043.06 04/07/2022 (7,5W <br />y_ / ' 4P )qs� 153 S l7 Page I of 2 Weil / Pump Permit <br />