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41 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 2/^09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS C CITYIZIP �� •_� <br />CROSS STREETI )1 F APN 10.? (,,', PARCEL SIZE �• <br />LAND USE APPLICATION # <br />OWNER NAME �S_Y \ U� Y S PHONE C>?() <br />OWNER ADDRESS CITY/STATEIZIP_ cldw C/+ <br />CONTRACTOR t;, <br />CONTRACTOR ADDRESS �ltd 1� �� CnY/STATE21P <br />SUBCONTRACTOR 5 <br />PHONE <br />SUBCONTRACTOR ADDRESS !CRy//STAT/E2iP / 1 <br />LICENSE DSC -57 ❑ C-61 -i D-09 ❑ Other NUMBER —e LV� { EXPIRATION DATE [ <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />11 "S XDomestic/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 />PA <br />TYPE OF WORK New Well D Replacement Well ❑ Well Alteration/Mod�cation Other <br />Monitoring Well(s) # of wells Soil Boring(s) a of borings r Geotechnical --�*� of <br />- Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair JSP <br />New Pum um Replacement ❑ Pum Repair Raise Well Casin S 8 <br />W ELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary D Air Rotary ❑ Auger Cable Tool Push Point ❑ Other NEq�T /RON /N CoU <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size q <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft Nmeter <br />Well Casing Diameter in Thickness/Gau a/ASTM Sched T <br />g Steel ❑ Plastic ❑ Stainless Steel <br />Grout Seal Depth ft 0 Neat Cement (94 Ib bag/5-10 gal water) _ Sand Cement <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method - Pumped , Free Fall i Other Retardant / Accelerator (name) <br />PEDESTAL Installed By _ Driller Pump Contractor <br />- Concrete Pedestal -Dimensions: Width_ <br />in 7 Christy Box - Stove Pipe <br />Other <br />ft Length ft Thick <br />❑ Other <br />sack mixR gal water <br />PUMP J�­Submersible ❑ Turbine ❑ Other <br />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 />\ll\I\il \I 24 1101 R AD\'-kNCL..NO1'WE. IkEQt IRL ) FOR INSPEC"PIONS - PLEASE CALL (209) 9, -53 -769 - <br />DEPARTMENT USE ONLY <br />Application Accepted By �L� Date F w 2 Area Lll cf Employee ID# / / � <br />Grout Inspection By !pate L SPECIAL Well Permit <br />Pump Inspection By r ��✓�` L` Date -WAIVER RCC@IVed <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS�s�r,,,,19e��1� :...,r n r}Ps •Li w.lr��• <br />.,, �"a Permit/ <br />Codes Info By_ Cash Remitted Date Service Request # Invoice # Well ID# <br />EHDo43-06 04/072022 page I of 2 <br />//!�[G Well / Pimip permit <br />D <br />ni <br />D <br />v <br />v <br />A <br />M <br />rn <br />to <br />