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I <br />WELL/PUMP PERMIT <br />SAN J7AQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />/ <br />O 1 ] CITY/ZIP pZ <br />CROSS STREET (� <br />APN 7� p 00 F; PARCEL SIZE USE APPLICATION # <br />OWNER NAME <br />_LAND <br />PHONE cvey^ y`s5-=aa9Z <br />t� <br />OWNER ADDRESS 1 <br />,o <br />(� CITY/STATE/ZIP <br />b, ^ CA <br />r `c% l� <br />CONTRACTOR I <br />` C � <br />J PHONE D l ^ <br />CONTRACTOR ADDRESS <br />CITY/STATE21P� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP7V�� <br />LICENSE -kC-57 D C-61 ` D-09 ❑ Other NUMBER %O EXPIRATION DATE I / 31 /1)7 -3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) , <br />INTENDED USE < bomestic/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 E Well Alteration/Modification 1 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 />= <br />MCI. New Pump Pump Replacement E Pump Repair Raise Well Casino <br />!` <br />Drilling Method Mud Rotary ❑ Air Rotary Auger Cable Tool Push Point E 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 C Stainless Steel �] Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />sack mix/7 gal water <br />= Bentonite (20% solids) 17, Other <br />Grout Placement Method Pumped Free Fall -1 Other 7 Retardant / Accelerator (name) <br />Installed By _ Driller L1 Pump Contractor <br />Concrete Pedestal -Dimensions: Width _ <br />Christy Box Stove PiDe <br />Other <br />ft Length ft Thick <br />I rump , ,5ubmersible E Turbine ❑ Other HP 112– Pum Set <br />P 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 />'IINIA[t'NI24IIOUR aDNAN('E NO1'ICT RI%.Q['IRED FOR INSPT(TIO\s- I'Li;_kSL (':1LI. 121)9) y;; r - <br />DEPARTMENT USE ONLY <br />Z' <br />Application Accepted By [�G' Date ( Area r r% Employee ID# 4:.7 <br />Grout Inspection By Date i SPECIAL Well PeOait_ <br />Pump Inspection By Date`t 1-,. �� lT'T <br />�—�` -- WAIVER ReCeIV���s <br />EHD043-06 04/07!2022 <br />'.g. r °r <br />Well / Pump Permit <br />5P <br />D <br />