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1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENvtRONMENTAL 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 /> LUZ Man GCA, 60 �j /� rn <br /> Joe ADDREs$ c, IP ✓� Y�Y/Z . :4 <br /> m <br /> CROSS STREET ► 1 'APN 20� 1 V VPARCEL SIZE LAND USE APPLICATION# o <br /> A <br /> OWNER NAME 1r/ PHONE 1 �Jy' � 1% � 0 p� <br /> OWNER ADDRESS ✓ r 1 CITY/STATE/ZIP 7 UA17 <br /> CONTRACTOR 1 OUIQ I G PHONE g�l/ Ir'L�r <br /> CONTRACTOR ADDRESS ' CtTY/STATE/ZtP ,► ` , G a q v/ �/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDREss CITY/STATEMP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER !>—U12 <br /> —U EXPIRATION DATE� <br /> DOMESTIC WELL SAMPLING:C Genera Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private gallon/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 3,New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other MF,y, <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical to of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing S v ?D <br /> WELL CONSTRUCTION EN O,q Q ?� <br /> Drilling Method ud Rota ❑ Air Rotary ❑ Augerrl El Cable Tool Ll Push Point Li Other hEq C /RO/V COV <br /> Proposed Well Depth VO ft Excavation /� in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diam <br /> C Conductor Casing in diameter I Conductor Casing Depth I it MFIV7 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal epth ft ❑ Neat Cement(94 Ib bag(5-10 gal wafer) nd Cement sack mix/7 gal water <br /> mon (20a/o solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor C Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length It Thick <br /> in ❑ Christy Box ❑ 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 /> PI,...s:,... ,. <br /> DEPARTMENT USE ONLY <br /> 7 <br /> Application Accepted By - L �— Date Area L1 �'�'" Employee ID# <br /> Grout Inspection By G24^ytr16 Date 1:jyl`11 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> L <br /> f HD043-06 10!152021 ��� ''V [�/� /...J [ �� age t of t Well/Pump Permit <br />