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l WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT , LL (209),A53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> m <br /> J 6 -� APN (�V �+� D <br /> CROSS STREET <br /> PARCEL SIZES L LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME \V>S PHONE � �% ) I S1 <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR — J4 PHONE <br /> CONTRACTOR ADDRESS A CITY/STATE/ZIP [ V01V�fi/7l <br /> Z� <br /> At <br /> SUBCONTRACTOR a <br /> PHONEb / Zy � i7b <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP q <br /> 7 s \ <br /> LICENSE '71 C-57 ❑ C-61 ❑ D-09 Li Other NUMBER EXPIRATION DATE���.3� <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Omestic/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 ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical °rings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAND <br /> Ll New Pum El Pump Replacement El Pump Repair 71 Raise Well Casing0 <br /> WELL CONSTRUCTION F Ty O/y"V OUN� <br /> Drilling Method>0,Aud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other ��pgR7*a.— � <br /> Proposed Well Depth SO ft Excavation /_L- in diameter ❑ Open Bottom Gravel Pack/Gravel Size_ in alaMeter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter O in Thickness/Gauge/ASTM SchedZ---O ❑ Steel j$Plastic ❑ Stainlqss Steel ❑ Other <br /> Grout Seal Depth /0`0 ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method A4:Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contracto ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in a Christy Box ❑ Stove Pipe <br /> PUMP Aaubmersibleo Turbine ❑ Other HP_ 2_ 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DP RTMENT U E ONLY <br /> Application Accepted By Date l W Area -1 ! Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By rCf �a�- Date UI I ti3 ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS QC r .� J <br /> w w <br /> n,. <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> o tZ �{ <br /> r � <br /> 1 2 <br /> ERD043-06 10/252021 Page 1 of 2 Well/Pump Permit <br />