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.1 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Alr')KI-0colI&m n.. -nom-..._ <br />ImIns I <br />t ALL JZUVJ 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS '45I <br />CITY/ZIF� <br />CROSS STREET <br />APN DFS J I 007 <br />' <br />PARCEL SIZE Ofc <br />_LAND <br />USE APPLICATION # <br />OWNER NAME <br />��jy� <br />PHONa L_.fI��L i <br />OWNER ADDRESS <br />7 �, <br />CITYISTATEIZIP <br />CONTRACTOR <br />/� <br />PHONE <br />CONTRACTOR ADORES <br />CITYISTATEIZIP<s.'id� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CrYYJSTATFJZIP <br />LICENSE x: C-57 :J C-61 <br />❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATE 3t <br />DOMESTIC WELL SAMPI mr_ <br />-- •-••• • - val lc ,a 1Yoy ,) uiuromocnloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural E Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />r ' Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />- Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />Out -Of -Service ell ❑ Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />WE�CONSTRUC�ONum Re lacement E Pum <br />New Pum PRepair ❑ Ra <br />Drilling Method - Mud Rotary Air Rotary ❑ Auger Cable Tool Push Point ❑ <br />Proposed Well Depth ft Excavation in diameter E Open Bottom <br />- Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thi k <br />`tp.9o V` <br />/y FNlO4 Q(J//� r <br />Other <br />Gravel Pack/Gravel Size QFC ' di 4 <br />ft TMFtiT <br />is ness/Gauge/ASTM SchedSteel ,: Plastic ❑ Stainless Steel El Other <br />Grout Seal Depth ft -7. Neat Cement (94 lb bag/5-10 gal water) E Sand Cement <br />- Bentonite (20% solids) Other sack mixl7 gal water <br />Grout Placement Method -. Pumped 7. Free Fall Other -; Retardant / Accelerator (name) <br />Installed By Driller ❑ Pump ContractorOther <br />Concrete Pedestal Dimensions: Width 'ft Length ft Thick <br />_Christy Box Stove PiDe <br />PUMP Submersible E Turbine ❑ Other HP Pump Set ft Standing Water Level w <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 />\IISUII \1 21 IiOL R A1)\ .1\CF. N0110E RLQL IRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �� L� Date 11 <br />Grout Inspection By Date <br />Pump Inspection By i Date ;'.,`. <br />Soil Boring Inspection By ) Date <br />COMMENTSwlr;n t C ) rr w , tF <br />I "RC1°C" �.necKf Amount Permit <br />Info By Cash Remitted Date Service Req <br />��des <br />SCr 1 S� t �a i_,r <br />Area r- <br />j Employee ID# =re r,l< <br />❑ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />#I Invoice # <br />Well ID# <br />EHD043-0604/072022 Page 1 oft <br />We11 /Pump Penni! <br />ft <br />rn <br />D <br />