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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 f� CALL/209 95n3-7697 FOR INSPECTIONS E/X�PIREfS�1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` V U, �� <br /> ���r�� CITY/ZIP G_1 m <br /> / l D <br /> CROSS STREET V`L' APN o a 11`i o C PARCEL SIZE _LAND USE APPCATION# A <br /> OWNER NAME l� J// �(_/� PHONE rn <br /> to <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �r. gS'Sr-�[i[= ��L/ ,PH-ONE ��L4� <br /> CONTRACTOR ADDRESS �d `,tom CITY/STATE/ZIP Com/V//�C flr2`( <br /> SUBCONTRACTOR 7 / � 6,�C / ��/► PHONE <br /> SUBCONTRACTOR ADDRESS CITY <br /> -/ <br /> ST <br /> ATE/ZIP <br /> LICENSE 4-57 C-61 D-09 Other NUMBER ? //Je7f EXPIRATION DATE <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/Charactert_o <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number CTKen <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> #of borings f/ f borin s <br /> Monitoring Well(s) #of wells Soil Boring(s) Geotechnical _ ✓(�A g <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Re air N CNV/R""/,vC <br /> New Pum Pum Replacement Pum Repair Raise Well Casingp ��ry40 MFVPAI <br /> 7U _ <br /> WELL CONSTRUCTION MENS, <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other /e <br /> Proposed Well Depth :5:0 ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br /> Conductor sing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GaugeiASTM Sched 'L Steel )Wstic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) -Sand Cement 17 s` sack mix/7 gal water <br /> 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_Z__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 loc ion 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 NO'l WE REQUIRED FOR I-,SPEC 110NS-PI.F:ASF:CALI.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> f' 7 <br /> Application Accepted By � /`l ( \\ Date k °7� Area qq Employee ID# r ,` <br /> Grout Inspection By � �m 13�w;1 ►►,��NI1_ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �_, �� /lyLnr Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS r m l D o se'.` cls tt -S-?C >.S <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cas Remitted Service Request# <br /> 366 19014,0D2 ,�O 2 <br /> 39 1SS <br /> H390 v s) I S�- <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />