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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (:ALL (ZUU) UbJ469/ FOR INSPECTIONS tAIJIKt.b 1 YEAR FROM UATE ISSUED <br />LE <br />JOB ADDRESS / S-/ CITY/ZIP Zo 19c <br />CROSS STREEJ�/X(,J 4- tL &(gkAftV-APN dl IS C7 7 9 PARCEL SIZE S LAND USE APPLICATION # <br />OWNER NAME 6- <br />OWNER ADDRESS�v,��+ <br />CONTRACTOR Gm`r <br />CITY/STATE/ZIP <br />PHONE '71?1 <br />�y/�� 1 /P'HONNE .3.7y-- n//y. 71' <br />CONTRACTOR ADDRESS _ no r2pl ry CITY/STATE/ZIP 4 �V7Y-C- <br />7Jj�l/(`��r A_ <br />SUBCONTRACTOR 13a 4 4j,A S �`/Y� PHONE L- 2 -?N> <br />ADDRESS <br />LICENSE _kC-57 C-61 D-09 i Other <br />CITY/STATE/ZIP <br />NUMBER of EXPIRATION DATEy _ <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 />F different from Owner: Water System Name <br />TYPE OF WORK -New Well ,( Replacement Well Well Alteration/Modification i Other <br />Contact Name or Phone <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings i Geotechnical AAt # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair 82022 <br />ew Pump i Pump Replacement I Pump Repair i Raise Well Casing UANJ <br />WELL CONSTRUCTION HEg1 NI �DNMENTq� N <br />Drilling Method >"Mud Rotary Air Rotary i Auger Cable Tool Push Point Other QEF <br />Proposed Well Depths rift Excavation ZZ in diameter Open Bottom 34ravel Pack/Gravel Size I diameter <br />Conducto Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Z-00SteelPlastic Stainless Steel Other <br />Grout Seal Depth` ft Neat Cement (94 /b bag/5-10 gal water) Ixand Cement A71-7 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By XDriller Pump Contractor Other It <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box 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 />MINIMUM 24 EIOUR kDVANCE: NOTICE REQUIRED FOR INSPECTIONS - PLE:ASF. C kld. (209) 953-7697 <br />DEPARTMENT USF ONLY p <br />Application Accepted By �— Z-1) Date v8 d� 2 Area "i Employee ID# / <br />Grout Inspection By �"" Date ❑ SPECIAL Well Permit <br />Pump Inspection By ��Gv� Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COM NTS _C -AISjT(�� el� y IC.b (%t (GY? iC:G FuY LaN(� i,�L� io-eirc"ki <br />T <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Pei mii <br />r FA <br />M, WfflmQ► <br />0 . <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Pei mii <br />