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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KEFUNUABLE VERMIT GALL (ZU9) 9bJ-1697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS -) k U <br />L— l \(-k% ) (.i r, ( i"\U <br />CITY/ZIP /,O <br />�l ( I t��� U <br />CROSS STREET <br />84NJO. <br />7 <br />APN Q G3 D eo I PARCEL SIZE _LAND USE ## <br />OWNER NAME <br />N^ VIRO OUAlAe <br />(AjPPLICATION <br />PHOjNEt 1 Ov(- <br />/^ <br />OWNER ADDRESS q 3 10 <br />(� <br />4�c�I,�de.�1- \ted <br />I <br />CITY/STATE/ZIP LOC.I,` <br />c il <br />CONTRACTOR �Olr <br />c <br />YY10�5 \ J�C�PL P�if`/ JLQ 5kni <br />S l VI C, <br />PHO_N/E Aq- 435/x-3�J10, <br />CONTRACTOR ADDRESS a I ao V l 1 /CU}C /�� <br />CITY/STATE/ZIP &k <br />Com- h C/ <br />�I / <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />Cl <br />71 <br />LICENSE C-57 ❑ C-61 <br />❑ D-09 ❑ Other <br />/T��Y/STATE/ZIP <br />NUMBER (t7 <br />EXPIRATION DATE <br />A/ <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE g 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ll New Hump A rump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ 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 ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack m5x/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 DDimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine D Other HP r Z 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 followinb 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 />NIII, IIIL �1 2-1 ilul7: ADN'�NCL N'01 I( E REAL iRED i (-)R INST'I'( TI<)_AS - PIT ASI ( kI-L (209) 9;;-70- <br />DEPARTMENT USE ONLY <br />Application Accepted By �— f-L�� Date as Area I / Employee ID# <br />Grout Inspection By A I Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS E>O c'tJlvl <br />Date Constructed Well Depth <br />ft <br />In <br />m <br />D <br />0 <br />0 <br />m <br />CA <br />y <br />PE <br />Codes <br />SC Received /Pl5eckiq Amount Permit/ <br />Info B Remitted Date Service uest# <br />Re <br />Invoice U� Well ID# <br />3$ <br />O 92 • �Q ' 2 <br />84NJO. <br />N^ VIRO OUAlAe <br />• r,'= qC <br />� �Te <br />[HD04]-06 10/2512021 <br />Page I oft <br />Well I Pump Pennit <br />