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I WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL (ZUU) 953-11jVf FOR INSPECTIONS <br />tXPIKLS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />i V��7 <br />p�1L' c C rY C )i L n - CITYizIP�% <br />�'C, t �� 5 �-4 C. <br />CROSS STREET <br />1 1 ,J <br />N Y 2S �) <br />/ '�-/ <br />APN nh ) 7 00-7 PARCEL SIZE � • r <br />LAND USE APPLICATION # <br />OWNER NAME <br />G -e- f-, I <br />A I t)e M c {" Z Jt <br />PHONE <br />CIjm <br />�Ct NlD <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR <br />\1 �A l `f <br />1 <br />PHONE :� c: c"i 36 9 -,?771 <br />CONTRACTOR ADDRESS P U <br />'7 <br />jj C. �. CITY/STATE/ZIP <br />Ct I+ . r A (1 J <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATEIZIP <br />LICENSE ) { C-57 J C-61 'I D-09 ❑ Other NUMBER �N'I30-5 EXPIRATION DATE 7—S <br />— `l <br />DOMESTIC WELL SAMPLING:)( General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE j9, Domestic/Private rl Irrigation/Agricultural ❑ Industrial -! Water Quality Monitoring ❑ Soil Sampling/Characterization YA <br />Public Water System RF/ <br />If different from Owner. Water System Name Contact Name or Phone Number �r <br />i <br />TYPE OF WORK New Well X Replacement Well ❑ Well Alteration/Modification -_ I Other <br />7 <br />11Monitoring Well(s) # of wells ❑Soil Boring # of borings s) [I Geotechnical .1# of borings / <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair --cqN JQq <br />I New PumD J Pump Replacement ❑ PumD Repair ❑ Raise Well Casino N�ENV/R Q�/N r <br />WELL CONSTRUCTION " n pEp"c N <br />Drilling Method )(,Mud Rotary :1 Air Rotary J Auger ❑ Cable Tool G Push Point ❑ Other A R r <br />Proposed Well Depth =? c ft Excavation )i in diameter ❑ Open Bottom V Gravel Pack/Gravel Size V-1 in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter C in Thickness/Gauge/ASTM Sched 2 ❑ Steel Plastic , Stainless Steel C Other <br />Grout Seal Depth kc ft fl Neat Cement (94 lb bag/5-10 gal water) P -L Sand Cement !Q _S sack mix/7 gal water <br />❑ Bentonite (20% solids) fl Other <br />Grout Placement Method 1A Pumped ❑ Free Fall 11 Other ,_ Retardant / Accelerator (name) <br />PEDESTAL Installed By VDriller J Pump Contractor C! Other <br />❑ Concrete Pedestal 1_]Dimensions: Width _� ft Length 5 ft Thick <br />in ❑ Christy Box -1 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />�7 ) DEPARTMENT USE ONLY r I <br />Application Accepted By GTz L L— Date 7 7A7 Area Employee ID# i'fGiyl�� <br />Grout Inspection By Date s ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMFNTS EXISllinS %d e 40 f e,1101 , f ! } -Z <br />rn <br />D <br />0 <br />A <br />N <br />AE7O <br />G <br />PE SC Received <br />Codes Info B <br />Check#/ Amount PermiU <br />Cash Remitted Date. Service Request # Invoice # Well ID# <br />►ss <br />O 6 <br />FHD043-060407/2022 Pngc I ur2 <br />AW �1YT.3v2-11/ <br />Well / Pump Permit <br />