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r <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN Ct _.., -nviRONMENTAL 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 (O l�Vr r/H : CITY/ZIP <br /> /r� <br /> CROSS STREET N 2521-1 1=&Z—PARCEL SIZE � � LAND USE APPLICAATION�#/ � <br /> OWNER NAME �� PHONE <br /> OWNER ADDRESS ` �45�7�/y /NNA/I �, / �t40� 0-CITY/STTATTE/ZIP <br /> CONTRACTOR '/Ir//V///,�!//I�'�> r7 d /LCA PHONE <br /> CONTRACTOR ADDRESSy�li� ��/—C�l / CITY/STATE/ZIP _5//(/w <br /> SUBCONTRACTOR D �s�le D Pl­�E <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE �C-57 W-61 El D-09 ❑ Other NUMBER ` 6WX EXPIRATION DATE L �G <br /> DOMESTIC WELL SAMPLING:)(General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)yArsenic(4393) <br /> INTENDED USEomestic/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 )V2epiacement 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 Cl Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud Ro ary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other0 Of <br /> Proposed Well Depth &"- ft Excavation in diameter ❑ Open Bottom ,WGravel Pack/Gravel Size in/�diiaameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft ~r ANE T <br /> Well Casing Diameter (0in Thicknes /Gauge/ASTM Sched de L Z4V❑ Steel�F'lastic ❑ Stainless Steel ❑ Other D <br /> Grout Seal Depth�ft 'Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal w t r <br /> Bentonite(20%solids) � Other SEP 2 <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) — <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other EMno.,.r.. NTY <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick HEAT Tu rnrr,. n <br /> in ❑ Christy Box ❑ Stove Pipe NT <br /> Eu-_MP 5ubmersible❑ Turbine ❑ Other HP 2 Pump Set ft Standing Water Level V -fit <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 /> NIININIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> -PLEASE GAIL(209)953-7697 <br /> DEPARTMENT USE ONLY Q <br /> Application Accepted By L Date �% r'3 .+-Z Area �%�j Employee ID# ✓t <br /> Grout Inspection By Date 12A I I 22 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Z 2 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Xl'St4i z-Jell -tvb(` f.fes !1 3o ZZ iN r eym,l r nb4dol onffAt-lor <br /> cf-Y4.4 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B C Remitted Date Service Request# Invoice# Well ID# <br /> �13�o C, se#I 2 2 <br /> X370I F0 wpon43,935 <br /> 3q1 WR00 343 <br /> 313 #aa II IrM 3 <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Perndt <br />