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r <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABBLE PERMIT / II (ZUy) !JbJ-[b9f FOR INSPECTIONS tAPIKtb 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /L. r15- (� Lrm rL �,� ' Qr ,res�ar �ns� CITY/ZIP 9S3 7' <br />/ /�`f8- ��%` OJ D <br />CROSS STREET�,_/, ,,(,,.,�z B, / �. APN �.�/8 ,Z�/���/%'d)? PARCEL SIZE t• /f LAND USE APPLICATION # <br />Np <br />OWNER NAMEis*..,Mrt r9A'��-r.1�' d /.�.C. PHONE C/ <br />OWNER ADDRESS ),a'lrCITY/STATE/ZIP <br />CONTRACTOR ���{ C/� 'GAr:"F'�.�ne-.�-,.. CCy�hR�t.�-c a�iyy�.L�/iGiRr.-. PHONE (10%)C'3$Z't/GiSi� <br />CONTRACTOR ADDRESS ?oZ r / �t/rir CITY/STATE/ZIP <br />SUBCONTRACTORPHONE <br />SUBCONTRACTOR ADDRESS ;'�C/G CITY/STATE/ZIP <br />LICENSE �fC-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 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 i i New Well Replacement Well Well Alteration/Modification Other <br />I Monitoring Well(s) # of wells Soil Boring(s) # of borings X Geotechnical 3 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New rump LJ vump Ke lacement F-ump Ne air Katse Well (:asin <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary � Auger Cable Tool -i Push Point a Other <br />Proposed Well Depth 15-40 ft Excavation in diameter Open Bottom I Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel a Other <br />Grout Seal Depth 15-0 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 />LJ Concrete Pedestal uDimensions: Width ft Length ft Thick <br />in ❑ Christy Box I 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 />Nil AINII NI 24 1101 R NDN VN( L NOII( 1 1(1.0111(1 1) 1 O INSI'l-A IIONS - PLEASE ('AL1 (209)953-7697 <br />DEPARTMENT U9,E NLY <br />Application Accepted B_ Date 22 Area <br />Grout Inspection By Date ❑ <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS (2) k — <br />Date <br />Employe <br />PECIAL Well Per /� N7. <br />WAIVER Receivepecritn A <br />PE <br />Codes <br />SC Received Che Amount Date Permit/ Invoice # HD�p <br />Info By Cash Remitted Service Request # <br />13 71— <br />15� La 217- <br />EHDO43-06 10/25/2021 Page I ort N cll Pump Pcrmii <br />