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1 0- WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE FEERMIT �'/♦► (:ALL (2U9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Z• (SS 1 I Mae- k V 110 y �d . CITY/ZIP O�'L �I •CV� � J (_ <br />CROSS STREET C_I he24 APN �I, D�_- "L -3O PARCEL SIZE AND USE APPLICATION # <br />OWNER NAME CI VAI _WCA <br />,p PHON,IEo o / `• (,-(-74G <br />OWNER ADDRESS pL- /✓ • Y 11 C. (� I' �G. \ CITY/STATE/ZIP I�Y-lC.:'`/� ` I;r 5&-3 <br />CONTRACTOR �W (�k46f"A PHONE <br />CONTRACTOR ADDRESS ('� e 1/l I V CITYISTATE/ZIP G CkS3 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/S <br />T <br />iATE/ZIP ^� <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER [ o`/ % 5( EXPIRATION DATE r <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private JKIrrigation/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 Wells) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />JeNew PumD ❑ PumD ReDlacement ❑ Pumo Repair ❑ Raise Well Casino <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__FAYAAfif4fr <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft RECEIVED <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cements k�mix/7rgak watgr <br />❑ Bentonite (20% solids) ❑ Other .JJ LL J LLUU [L <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other HEALTH DER.A. .:�. <br />❑ Concrete Pedestal DDi ensions: Width ft Length ft Thick <br />�in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SubmersibleN Turbine ❑ Other HP l V V Pump Set h h0 ft Standing Water Level ZS"�;' 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 />P TMENT SE ONLY /� <br />Application Accepted By Date 2 ! fin_ Area 7 Employee ID# <br />Grout Inspection By /� ,� Date ❑ SPECIAL Well Permit <br />Pump Inspection By �;)(0 �c.B�k 2v>_ Date im Cl WAIVER Received <br />Soil Boring I,,n[ppection By Date Constructed Well Depth ft <br />New ew we) O QCq 3 o2 d - <br />PE SC Received Check#/ Amount Permit) <br />Co s Info y Cash emitte Date J=ice Re uest #00 4 .4 Invoice # Well ID# <br />E•HDO43-06 04/07/2022 Page l of 2 Well / Pump Permit <br />