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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,�yI a rn <br /> JOB ADDRESS !�L t o 3 Q J A5 ;,A � ` CfTV/ZIP (�/��Vl/l. r4 , C'1 -1 W m <br /> CROSS STREET APN T2q -OSO 119 O PARCEL SUM? 124a.AND USE AnPPLICATION/# p <br /> OWNER NAME l 'eCtPA-C. Vf I J S <br /> . -TIrw PHONE <br /> f,316F CRY/STATE/ztPiA1lf C!A��/h Z 15331. <br /> S 3✓3"4OWNER ADDRESS6r <br /> CONTRACTOR M.s�q1 t is (,`r_�l ll♦ (Tti1C. �/�PHONE S ZZ/'���ZQ'9 <br /> CONTRACTOR ADDRESS 1 ` A t`-c� 1 • CRYISTATErzw 1•'o�e S A . ( rn 7 S 3 57 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CITY/STATE/ZIP ,, <br /> LICENSE 75r C-57 ❑ C-61 Li D-09 ❑ Other NUMBER�,G'Z7i ExPtRATwm DATE 2 <br /> y'��-' <br /> DOMESTIC WELL SAMPLING: :General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392), Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private IRigatiort/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampiing/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water System Name Corded Name or Phone Number <br /> TYPE OF WORK .New Well [Replacement Well ❑Well Atteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) a of°'"mora ❑Geotechnical a of bO""gs <br /> C Out-OfService Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CoN3TRUCTIDN <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger Cl Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth Iso ft Excavation 0 in diameter 7 Open Bottom 3f Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 172 in Thickness/Gauge/ASTM Sched Z a L7 Steel [(PlaS6C ❑Stainless Steel L Other <br /> Grout Seal Depth_ 1—7 O _ft ❑ Neat Cement(94 1b baq/5-10 gal water) f] Sand Cement sack mbd7 gal water <br /> ,(Bentonite(20%solids) ❑ Other <br /> Grout Placement Method K Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller XPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stow 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 tines. 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 1 <br /> Application Accepted By "��! Date 3 � � Area S' �C 111t�L, Empioyee tD#�� <br /> Grout Inspection By C�L Date - y ❑ SPECIAL Well Pell"Mit <br /> Pump Inspection By Date !7 WAIVER Received _ <br /> Soil Boring Inspe//ction By Date_ Constructed WalDepp.l ft <br /> COMMENTS NL,T t°�JCkt Lu / G r:.r r ;C�lr , /72 r CL ��t)^/ 6-letC Q 4Pf Q <br /> " 20& 4id e,"—: ' a cl l-4 ',!,a t&ni i v <br /> PE SC Received Checks/ Amount Permit/ <br /> Codes Into B Cash Remitted Vats Irv( !guest 0 Invoice C Well IDC <br /> LHD071-06.10'25.2021 ZSZ� Pnge I oft Well/pmv Perms <br /> Fes' <br />