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ff <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL fqnm 953-7697 <br />11 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1 � -� � <br />CROSS STREET ii(L I rv_ C LSC APN 217 PARCEL SIZE ") J` <br />LAND USE APPLICATION # <br />OWNER NAME t✓ 7 I. - ��, �(/� _ l / i]�� <br />11 PHONE!, .,/il 1 1 ! ll• �i / - <br />OWNERADDREs$ r I1 <br />_1 � / + �; �— � Jt• Y'�"iclt iD+ RA 11,/ <br />CITY/STATE/ZIP_- <br />L,� <br />p i <br />CONTRACTORq <br />I-'�/ (r f . �" ` <br />zz PHONE f-jr:.Ff 1 J <br />CONTRACTOR ADDRESS _J JV %� • r <br />CL <br />CITY/STATE/LP +Li CISC(% <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEIZIP <br />LICENSE C-57 0 C-61 0 D-09 0 Other NUMBERL\ EXPIRATION DATE ). 21:' <br />_ <br />DOMESTIC i6VELL SAMPLING: �­ General Mineral/Coliform Bacteria (4391) . , Dibromcchloropropane (4392) R Arsenic (4393) <br />INTENDED USE /,�omestic/Private 11Imigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name , Contact Name or Phone Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification .Other ; <br />" 1_)6 �XtS+Its 1 7► t ��? <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) ■ of borings ❑Geotechnical u or oringa <br />❑ Out -Of -Service Well n Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />❑ New Pump E Pump Replacement APumpRe2air % i7vyrr r �C� C Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 7! Air Rotary C Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter L' O ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conduc g Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/AST ❑ Steel ❑ Plastic ❑ Stainless Steel ;; Other <br />Grout Seal Depth <br />ft ❑ Neat -O ment (94 lbbag45-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />U Bentonite (20% sol Other <br />Grout Placement Method ❑ Purriped ❑ Free Fall a Other ❑ Retardant / Accelerator (name) <br />ESTAL Installed By ❑ Driller Pump Contractor C Other <br />❑ Concrete Pedestal ODI enslons: Width ft Length ft Thick <br />fin <br />0 Christy Box 7 Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set 1 `� it v <br />i Standing vvatcl I_Bve1 f n <br />,Z/ <br />Plot Plan Regwrements. Attach a plot plan with the exact location of water well with respect to the following <br />items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, <br />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 �+ Z_ l- Date <br />Area Employee ID# r ,' - %< <br />Grout Inspection ByA Date <br />C SPECIAL Well Permit <br />Pump Inspection By Date C WAIVER ReceiVed <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount <br />Codes Info B Date <br />Permit/ <br />Cash Remitted <br />Service Request # Invoice I # <br />_ <br />2022 <br />ENVIR NMENT,4 <br />nw43w 04iMZ022 Page I of S <br />(00( 4� 01 125-, <br />rICHL I I-1 IL) L FiA. IT l.'4�iT,� <br />