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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE FLE/RMI (:ALL 109 95" fb9f FOR INSPECTIONS I=AFIKtt=,,'I/YEAR FROM DATE ISSUED <br />JOB ADDRESS���y ���[ lis •—_ CITY/ZIP C <br />it <br />CROSS STREET !/ f /Q� /�//� APN o5 PARCEL SIZE 1(!!; LAND USE APPLICATION # <br />OWNER NAME �If %2 •y �f /(,J��,.7yY1 Q PHONE [ � v Zso/� <br />✓ <br />OWNER ADDRESS t� ����w T CITY/STATE/ZIP <br />CONTRACTOR Gf <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />i'.3' R� % %- / /PHONE <br />CITY/STATE/ZIP <br />PHONE Z7- '��Z✓ <br />LICENSE J:&-57 C-61 D-09 _ Other <br />CITY/STATE/ZIP <br />NUMBER ;7 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: A 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 ew Well Replacement Well Well Alteration/Modification I. Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings i GeotechnicalL` � <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair /A <br />ew Pum - Pum Replacement Pum Repair _ Raise Well CasingA <br />WELL CONSTRUCTION SAN <br />Drilling MethodU<TAUd Rotary I i Air Rotary i Auger i i Cable Tool -! Push Point i i Other C1qQU/N <br />Proposed Well Depth ft Excavation 12, in diameter Open Bottom Gravel Pack/Gra MEN � d a eter <br />Conductor Casing in diameter / Conductor Casing Depth ft TMENT <br />Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched Steel �eastic ` Stainl s Steel Other <br />Grout Seal Depth q,� ft Neat Cement (94 Ib bay/5-10 gal water) and Cement . sack mix/7 gal water <br />i Bentonite (20% solids) I Other <br />Grout Placement Method dumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By -44)riller Pump Contract' Other <br />Concrete Pedestal Dimensions: Width 7 ft Length ft Thickoge <br />�in Christy Box 1 1 Stove Pipe <br />PUMP J'C ubmersible 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 />MININIL NI 24 HOUR ADVANCE: NOTI( E: REQUIRED FOR INSPECLIONS - PLEASE. ('%1,1. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted ByL�>y L Date Ih e, 2 Area / _/ ! Employee ID# Ff", Y, i <br />Grout Inspection By Date 2 ❑ SPECIAL Well Permit <br />Pump Inspection By VV Date AL ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS Er+'eyln as-IdIPss jil� 830 , ti.,t'nj.-jel }U 7eYY1GiN vi itA Rr,--or 4f4cf-,r <br />Wr <br />D <br />0 <br />0 <br />m <br />ti <br />r-HD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />r MY= : I <br />� <br />HMIM19,1qNs1SIL� <br />CM <br />Vc����E�n�� <br />Effl. <br />�J��I�zZ•�AIIG�II� <br />r-HD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />