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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />'JOB ADDRESS 6 CITYIZIP <br />CROSS STREET APN 1 D (d 031PARCEL SIZE d , J % <br />p LAND USE APPLICATION # <br />OWNER NAME �� PHONE <br />OWNER ADDRESS <br />� CITY/STATE/ZIP <br />CONTRACTOR ) i PHONEb� a�l <br />CONTRACTOR ADDRESS <br />CnY/STATE21P <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />n C /STATE2IP <br />LICENSE C-57 ❑ C -61D-09 � Other NUMBER ��J I 1 EXPIRATION DATE / <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteda (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE E 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 -1 Replacement Well ❑ Well Alteration/Modification Other <br />Monitoring Well(s) # of wells []Soil Borings) # of borings r Geotechnical # of borings <br />Out -Of -Service II 11 Out -Of -Service Well Renewal FJCross-Connection Repair <br />-. New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary ❑ Air Rotary Auger = Cable Tool ❑ Push Point Other <br />Proposed Well Depth ft Excavation in diameter o Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Sched D Steel ❑ Plastic ❑ Stainless Steel Cl Other <br />Grout Seal Depth ft ❑ Neat Cement (94/b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />Bentonite (20% solids) ❑Other <br />Grout Placement Method Pumped 7i 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 OK Submersible Turbine i Other HP Pump Set / <br />/ % 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 />NHNIMUNI 24 HOUR ADIVANCE NOTI(T REQUIRED FOR INSPE('TIONS- PLEASE CAI.I. (209) "3 -769 - <br />DEPARTMENT USE ONLY <br />f <br />Application Accepted By L �L� Date <br />Grout Inspection By Date <br />Pump Inspection By � Date _ ( C, c a' <br />Soil Boring Inspection By 1 Date <br />COMMENTS Dcp <br />PE <br />I <br />Date �` <br />Service <br />O <br />0 <br />M <br />M <br />w <br />(A <br />Area r r-,/ Employee ID# f `,t 11 <br />_i SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />1 : 21,t.'. <br />#I Invoice # <br />END043-0604/07/2022 Page I oft <br />Well /Pump Perim[ <br />ft <br />