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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 E PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP m <br /> +� ^� l D <br /> CROSS STREET tV:rL4 APN l J 07O �" PARCEL SIZE LAND USE APPLICATION# o <br /> Q Q 2 m <br /> OWNER NAME � /l =� �/� g PHONE L .7 u <br /> SAOWNER ADDRESS 'm V CITY/STATE/ZIP <br /> CONTRACTOR — [/r PH,/O�NyE- T- IV 7 Z y <br /> CONTRACTOR ADDRESS 6) CITY/STATE/ZIP !( ��+�/g ��C� <br /> SUBCONTRACTOR `_� / �� PHONE Z7' 'ZD <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Akt-57 ❑ C-61 ❑ D-09 ❑ Other NUMBE 7736' EXPIRATION DATE 23 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural I Industrial ❑ Water Quality Monitoring n Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )eNew Well a Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 1 I 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 /> Clew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Xvlud otas ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depthft Excavation in diameter ❑ Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Schad Z..00 ❑ Steel lastic 11Stai ss Steel 7 Other <br /> Grout Seal Depth�_ft ❑ Neat Cement(94 lb bag/5-10 gal water) C�and Cement ZO., .3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped D Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ^riiler ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width f ft Length ft Thick <br /> in [' Christy Box ❑ Stove Pipe <br /> PUMP .N<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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> �^r� L <br /> Application Accepted By c �— 1� /-- p Date d Y aC) Area Employee ID# F <br /> Grout Inspection By C0 ^AL�;T� Date 'D ZZ ❑ SPECIAL Well P mit <br /> Pump Inspection By Date ❑ WAIVER Recei M4YtijFNT <br /> Soil Boring Inspection By Date Constructed Well Depth �C ft <br /> COMMENTS Fjofe.Oy y4tl& Shar►n� WCI • V4 j� c�tt1. 0111.. WAQU <br /> PE SC Received Amount Dto Permit/ InvoilyV/A <br /> Codes Info By Cash Remitted Service Request# R <br /> 3(,6 )$0 1�O EP,gRT <br /> g3c1I 4)S <br /> y3 go os 1 # )SOtk L4 <br /> InE <br /> EHD043-06 10/25/2021 Page l oft �_�(r/Jy�y"';y' J, Wely/i P /i <br />