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e <br /> >r <br /> 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 JO C O a S, C µP-I SM A to R OA—D CITY/ZIP _rPAC_�f L A y <br /> CROSS STREET I I%411e_Sou4-k of L-tnn� 25 3- 2¢0 -IU a -OOC 3.71��''E / D <br /> APN PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> OWNER NAME I'�I t�4.-(AM M ILL—�i/2 PHONE Yi <br /> OWNER ADDRESS S MVIL CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> PA i­ <br /> TSUBCSUBCONTRACTOR PHONE �[� / "/V7- <br /> SUBCONTRACTOR <br /> ONTRACTOR ADDRESS CITY/STATE/ZIP D <br /> LICENSE D C-57 O C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE O <br /> DOMESTIC WELL SAMPLING:�General Mineral/Coliform Bacteria(4391)�pibromochloropropane(4392)�Arsenic(439 ) EN OA(?(JIN CO <br /> INTENDED USE bomeslic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring O Soil Sampling/Characters i r) " �TY <br /> O Public Water System ART NT <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well O Well Alteration/Modification XOthe, ae is <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings e I I <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump O Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑ Auger O Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter O Open Bottom O Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched O Steel ❑ Plastic O Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) O Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) O Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall O Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> O Concrete Pedestal❑Dimensions:Width ft Length it Thick <br /> lin ❑ Christy Box O 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 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 /> MININIU1124 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> D PA TM ENT U E ONLY <br /> Application Accepted By� ' Date Area Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins'p'e1ction By ate Constructed Well Dept ft <br /> COMMENTS �IOVI^P,rS!/1yigI'_ te(, i4-G":'"AA n gcoot dPr- <br /> PE SC Received Check#/ Amount Permit/ <br /> odes Info By, Cash emitted Date Service Request# Invoice# Well ID# <br /> 31I L3 ��Pmm�+�+38� <br /> 2 <br /> it <br /> EHD013-0601!07!2022 page 1 ort Neil/Pump Permit <br /> C�.� ��sy�3g7ia <br />