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WELL/PUMP PERMIT <br /> SJ&JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> N6N-REFUNDABLE PERMIT CALL(2209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> e LA <br /> JOB ADDRESS -Z s P1 A111Stt9 A,n CITY/ZIP �i/s' � 5 1 <br /> M <br /> CROSS STREET <br /> ,�rr�� }�APN V Fq; Dy O S D <br /> PARCEL SIZE + LAND USE APPLICATION# O <br /> m <br /> OWNER NAME /,�/J • •S�� PHONE <br /> N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR //�'/[/(�`%i /I��/,�/� � ��(f� >Lt/L�_ � PHONN��a�19Fr!�'�ryr <br /> CONTRACTOR ADDRESS �! '� ��L���—c�Vly /�-7�/ CITY/STATE/ZIP ae% <br /> SUBCONTRACTOR PHONE <br /> ,Iwo v /! <br /> SUBCONTRACTOR ADDRESS ��ilsy � N�7 CITY/STATE/ZIP ? <br /> LICENSE VC-57 WC-61 Ll D-09 ❑ Other NUMBER / p / EXPIRATION DATE 7l <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/Characteykation <br /> ❑ Public Water System p <br /> If different from Owner: Water System Name Contact Name or Phone Numbe "h; <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> s borings <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings 9 ❑ Geotechnical V'°� 9 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casingy FNS/ QU/ <br /> WELL C•ONSTRU ION N pFpq EjyTq4 <br /> Drilling Method NMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 11 Other RrM <br /> Proposed Well Depth ft Excavation 12-11 in diameter ❑ Open Bottomravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter /,,, in Thi ess/Gauge/ASTM Sched_��ZCD ❑ Steel�lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth �F_ V Neat Cement(94 lb 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 /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible Turbine ❑ Other HP 2' 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 74 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY - <br /> Application Accepted By Z� -—� Date �d �� Area /'7 Employee ID# <br /> Grout Inspection By Z Date a�!` Z2 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 1 u�, �.�Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS i:J -Pcks}Q4 C. • 0' t <br /> (J'E TO v WtIWS -A <br /> PE Sc Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By, Cash Remitted Service Request# <br /> 3�° os 7 s •10.22n D3 <br /> 070 Fo 4 a o <br /> Wpo A0 <br /> L13 1 I 1 SS' _�hP <br /> EHD043-06 04/07/2022 Page 1 of 2 Well/Pump Permit <br />