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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 />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS nIR <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS L4 152— ff) o. o dc_ CITY/ZIP �' 6 `v <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />0 <br />CONTRACTOR ( I la <br />CONTRACTOR ADDRESS CR <br />APN 17 9 - ZOo-/ 7 <br />PARCEL SIZE �' Z / LAND USE APPLICATION # /_ e <br />PHONE ciQ /'� 0( <br />/ <br />7— (/ <br />CITY/STATTEIZIP SAl, <br />/j <br />(� <br />`k' PHONE <br />!/ J9�fj�/D <br />CITYISTATE/ZIP /Vl�L rl f c_S) C <br />SUBCONTRACTOR � / 41 PHONE A 14 <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE 1C C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE l 13( 123 <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 />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 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement K Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement �r�c,�i�c/7al water <br />❑ Bentonite (20% solids) ❑ Other 1�t� <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 MAY i <br />lin ❑ Christy Box ❑ Stove PIDe <br />PUMP XSubmersible❑ Turbine ❑ Other HP_ I Pump Set ft Standinc�NMRmNMIFNTAI ­ ' ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to ffLP%t1cW9P4►RFMfi tTGPS <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 />\IINI11L \I 24 HOt R kDN _-1NCI[ A01RE REQL iRED FOR INSPi:CT t(11ti • PL,U ASA ( 1LL (209) 9531-7,69 <br />DEPARTMENT US.71 LY C <br />Application Accepted By Date �� ZZ Area % 7 Employee ID#11� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date �� ��5��� ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Dat Permit/ Invoice # Well ID# <br />Codes Info k3y Cash Remitted S rvice Re est # <br />O % 2 <br />EHD043-06 10852021 Page I of 2 Well / Pump Pennit <br />