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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� U L� S- C:A9&- Q u A 0 CITY/ZIP ( 2 A (_L/ m <br /> ryry ss�� D <br /> CROSS STREET 1 I,:(J IVA)i APN l]r 01a v S 3 8 PARCEL SIZE LAND USE APPLICATION# O <br /> M <br /> 1, m <br /> OWNER NAME Ui?I P�>k-t� CID SCt) `/�,� PHONE 'sl C) <br /> OWNER ADDRESS 2-'1 L ^( S. C p q I: V0 A D CITY/STATE/ZIP (;L� (�A 21 S 3 0 <br /> CONTRACTOR � !/�F Y' PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 Other AVYI tV NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEf`Domestic/Private ❑ Irrigation/Agricultural Cl Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> E 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 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other PAYMEN <br /> Proposed Well Depth ft Excavation in diameter Ci Open Bottom ❑ Gravel Pack/Gravel Size R CS" <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched LlSteel [I Plastic ❑ Stainless Steel ❑ Other D- <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other 8AN JOAQUIN C U Ty <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) MVIR ENT <br /> T <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ^ / <br /> ,XConcrete Pedestal ❑Dimensions:Width ft Length Thick S. ini iS <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set Zj� 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 it ms: 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 /> 111NI11I 11 24 IlOt R AD\':kN( l:NOIR E REQI'IRI;I)1,OR INSI,EC-1 IONS-14.1:ASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> z �j�/ <br /> Application Accepted By ` L % /Date /� a Area J Employee ID# <br /> Grout Inspection By A . <br /> Date 11 SPECIAL Well Permit <br /> Pump Inspection By A . Date I C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS NevJ 1 Je,I O'4 v+�I W PU04d 3s a <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 14390 I�11 <br /> EHDO43-06 10/25/2021 Page I of 2 Well/Pump Permit <br />