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1 <br /> 1 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 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .JOB ADDRESS .-le CITY/ZIP Cd - <br /> r��7t /ice !� / m <br /> �f p� Z, D <br /> CROSS STREET LA� f�J� y, 'tAPN —770 �/ PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME Q / '/L 'c 1 N PHON , ©_ ?-7910 N <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR 144 a S-S PHONE J I ( 7 <br /> CONTRACTOR ADDRESS 1-7 c? CITY/STATE/ZIP iC�n I psi' <br /> SUBCONTRACTOR (r. YIDSS f n PHONE *3 1_7 43 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE .34-57-57 ❑ G7_C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE �-2 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE bl�Domestic/Private ElIrrigation/Agricultural ❑ Industrial 11Water Quality Monitoring ElSoil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK peNew 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 /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method AAud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 Zp ft Excavation —� in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductoo Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter v in Thickness/Gauge/ASTM Schad 'L-90 ❑ Steel .-Plastic ❑ StaipLss Steel ❑ Other <br /> Li Seal Depthft Neat Cement(94 Ib bag/5-10 gal water) 50and Cement sack rnW7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Methodo4umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> I <br /> PEDESTAL Installed By riller ❑ Pump Contractor ❑ Other IRNMENI <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick RECENVCII <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ;k:`ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the toiW. <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existi 1'A , <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property AMTHtD PAT MENi' <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 /> D PA TMENT U,,E/7>1,_A--_LY <br /> Application Accepted By4ZDate !/1 Area4k4q Employee ID# <br /> Grout Inspection By ' '0 Date Y/ a�&Z- ❑ PECIAL Well Permit <br /> Pump Inspection By f f Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth � •' ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> odes Ifo Cash 'emed Date Service Request#ZUD <br /> Invoice# Well ID# <br /> O V1 <br /> V <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />