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NPa!' 55 2s 0R <br /> . 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 14NON-REFUNDABLEPtERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,3 1 O3 ��(��(��� y n CITY/ZIP_T q SISN mLn <br /> ` 1�+ <br /> CROSS STREET W �y APN 23^Dq-*3 D <br /> PARCEL SIZE lW,LAND USE APPLICATION# 0 <br /> � �q <br /> OWNER NAME r 5 W(K ' q tti.� z <br /> Ta PHONE �" { �gOS " (oD(DZ m <br /> OWNER ADDRESS qDl 0, )r�en �r 1\� , GGI 44i 3C ��x ( �"'�O�-Ie O ,C/4 t5.� <br /> CITYISTAT /ZIPSk <br /> CONTRACTOR _ {_;�?��p(� l��roS.T�r:ll�"Zi ��G , PHONE <br /> �p� �^ fs.31 'lay- t 3 3 is <br /> CONTRACTOR ADDRESS V r f Po r �1v CITY/STATE/ZIP t��a SOS tJ•-�l Y7 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C 57 ❑ C-61 ❑ D-09 U Other NUMBER 5 <br /> EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial 1_I Water Quality Monitoring ❑ Soil Sampling/Charactenzalipn <br /> ❑ Public Water System N <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well n Well Alteration/Modification 11 Other <br /> CI Monitoring Wells) #of wells ❑ Soil Boring(s) It of borings ^ Geotechnical f�gb/7 <br /> 11 Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair SqN 20 <br /> ❑ New PumpLl Pum Re lacement ,❑ PumpRepair 11 Raise Well CasingJ04 2? <br /> WELL CONSTRUCTION <br /> 4 L tH© NM NC)A <br /> Drilling Method 9Mud Rotary 1-1 AirRotary -]'Auger J Cable Tool L Push Point ❑ Other 6Pq 14/ <br /> Proposed Well Depth ADO ft Excavation - 2 (2 in diameter ❑ e Open Bottom XGravel Pack/Gravel Size in diame er <br /> ,e CondUCtor Casing�—in diameter / Conductor Casing Depth -3 D ft <br /> Well Casing Diameter_& in Thickness/Gauge/ASTM Sched G� <Steel a Plastic CI Stainless Steel Li Other <br /> — <br /> Grout Grout Seal Depth 1 c ft ❑ Neat Cement(94 Ib bagl5-10 gal water) Sand Cement 10• sack mix/7 gal water <br /> Bentonite 0%solids) ❑ Other <br /> Grout Placement Method Xumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 'Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width--(o_ft Length ft Thick <br /> in ❑ Christy Box 11 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, .eater 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 /> DIINOR N1 24 1101 R AD\A.NCE.NOTICE REOIIRED FOR INSPE(-FIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY r <br /> Application Accepted By - Date �'! /� r,� Area S �i'U Employee ID# �! <br /> Grout Inspection By Date�� ��(���,�, 11 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received h Amount Permit/ <br /> Codes Info B Cas Remitted Date Service Re guest# Invoice# Well ID# <br /> D L4 Sol p <br /> E-ID043.06 10/25/2021 Page I of 2 <br /> Well/purrip Permit <br />