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1 t' 1 WELL/PUMP PERMIT <br />S.AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />&ON -REFUNDABLE PERMIT ��/ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />[CROSS <br />B ADDRESS r � G � � CITY/ZIP <br />STREETAPIN (� �Z�. 1 ) 3.3 PARCEL SIZE Lf'7,2LAND USE APPLICATION # <br />NER NAME <br />PHONE a��r - LIN - <br />Q' <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR OCC PHONE <br />CONTRACTOR ADDRESS ?10-20X <br />Crry/STATErZIP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CI Y/STATE21P <br />--A/74/4 <br />LICENSE NL,/C-57 J C-61 D-09 ❑ Other NUMBER/ 3/Z� <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteda (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ! Public i Water <br />ate 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 - New Well a Replacement Well ❑ Well Alteration/Modification ❑ Other <br />- Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings n Geotechnical # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pume A Pump Replacement E Pump Repair Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point 7 Other <br />Proposed Well Depth ft Excavation in diameter!Open Bottom Gr <br />Conductor Casing in diameter / Conductor Casing Depth ft Pack/Gravel Size in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel C Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft [ Neat Cement (94 Ib bag/5-10 gal water) 7 Sand Cement <br />_. Bentonite (20% solids) 11Other sack mix/7 gal water <br />Grout Placement Method Pumped Free Fall Other '' Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller -: Pump Contractor - Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in Christy Box - Stove PiDe <br />I ruMP XSubmersible _ Turbine D Other <br />HP 5 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 />MININIL l 24 1101 RADS :INCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By Date <br />Pump Inspection By -z4L� <br />Date (J <br />Soil Boring Inspection By <br />COMMENTS DCti�'�, <br />Date <br />1 6 'V" <br />Date <br />Area 96i Employee,D# Fcc Ytk <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br /># I Invoice # I A 1ji. lygll ID# <br />EHD043-06 04/072022 <br />Page 1 oft <br />Well / Pump Permit <br />co <br />D <br />D <br />z <br />fq <br />PE <br />des <br />13 ) <br />SC <br />Info <br />o> <br />=Received <br />III <br />Amount <br />ash Remitted <br />In h r-7-7 <br />Date <br />Area 96i Employee,D# Fcc Ytk <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br /># I Invoice # I A 1ji. lygll ID# <br />EHD043-06 04/072022 <br />Page 1 oft <br />Well / Pump Permit <br />co <br />D <br />D <br />z <br />fq <br />