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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 /> NON-REFUNDABLE PERMIT / �j CALL [209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �7 �S_I J�}//S •&4 MGe.7 ,� • CrryIZ�IP T����'7 . 9$-5774/03 m <br /> CROSS STREET S's�,�/�644 pi e.P AP 1� —I'�O�PARCEL SIZE 023 LAND USE APPLICATION# Q A <br /> OWNERNAME Y fz SMI���Vf PHONE16610279 <br /> Q6�—/�.n{�Qdlf5.,.,O rn• <br /> OWNER ADDRESS 13P9 CIY/STAIWZIP �e��ON�/� •/Y'�7 J2S/"�S�/ <br /> CONTRACTOR 009-Al Er��, �O/V Al�j PHONE /*90 5 32"?t t✓y <br /> CONTRACTOR ADDRESS f� LyG S t-/'} t`T . CITY/STAT E/ZIP� • /S r7 70 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Crry//STATE//Z�IP <br /> LICENSE SCC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER4.73 7y% ExPIRATION DATE 7 3� ��'Z- <br /> DOMESTIC WELL SAMPUNG:XGeneral Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)0 Arsenic(4393) PA Y E <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization VEI)❑ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I(New Well ❑ Replacement Well ❑Well Alteration/Modification ❑ Other 2021 <br /> ❑ Monitoring Well(s) #of wells ❑Soil Boring(s) #of bor ngs ❑Geotechnical n�®AQUI <br /> ❑ Out-Of-Service Well ❑ Out-OfService Well Renewal ❑Cross-Connection Repair HEA�T NME �UNT}1 <br /> 11 New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingH SEP A( <br /> WELL CONSTRUCTION T MENT <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑ Push Point 0 Other <br /> Proposed Well Depth—aita It Excavation 1 2— in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size Y in diameter <br /> ❑ Conductor Casing & in diameter / Conductor Casing Depth AZO It <br /> Well Casing Diameter to" in Thickness/Gauge/ASTM Sched 12-SO ❑ Steel XPlastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth&ea�_ft iXNeat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack m&17 gal water <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑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 ❑ 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 /> WI NIINIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -G Z_ Date 13 v7 I Area Employee ID# & <br /> Grout Inspection By s Date '7? 2z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By DateConstructed Well Depth ft •3�s•1/�� <br /> COMMENTS 1r•'t WC o' r! 7 CO;itrfiL401.7 Co ., J:11 "fr71-fi1f '�,iMrf vabeaIiFr <br /> eelle441f <br /> - <br /> PE SC Received Check#/ Amount Date Permit( Invoice# Well ID# <br /> Codes Info Cash Remitted J eryice e UPt# <br /> 366 3 O <br /> 4A t1S"O <br /> EHDO43-06 10/252021 Page t of 2 well/Pump Pamir <br />