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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT yr� J CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I`"/ ]1 0 t� ��` CITY/ZIP I PO N I W( M <br /> n 1 2��i - 'Jo t l�CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# G 1/J�,) S <br /> V ) `a • �v PHONE O �� y m <br /> OWNER NAME W <br /> y��-�1 r,� 'Y�f'r� Ul <br /> OWNER ADDRESS / ( 1 1� ^�` r, CITYISTATE/ZIP, wN A 1 � V v <br /> CONTRACTOR lV,� 'I1 J ��MN 1 V 0 'PHONE <br /> �(► <br /> CONTRACTOR ADDRESS �Iq 1 I/ �J�S CITY/STATE/ZIP I�1 I W� _� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C 57 C-61 D-09 Other NUMBER 42- EXPIRATION DATE '!O <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria(4391) Dibromochlompropane(4392) Arsenic(4393) <br /> INTENDED USE lluomestOPrivate IrrigationiAgricultural 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 replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) s of borings Geotechnical a or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud RoLary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well lepth ft Excavation �ZI in diameter Open Bottom Gravel PackiGravel Siz in diameter <br /> Conduct r Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched !- Steel I Plastic Stainless Steel Other <br /> Grout Seal Depth' it Neat Cement(94 lb bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br /> �Bentoni (20%solids) Other <br /> PAYMENT- <br /> Grout Placement Methodt Pumped Free Fall Other _ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick 20233 <br /> in 7 Christy Box Stove Pipe <br /> anN_ <br /> E VIHO M11 <br /> PUMP Submersible Turbine Other HP Pump Set ft StandingWataarrneNi 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, properh• 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 /> X-riculture. Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> ,11NIUi 112411(IlR �IWNN(I•: \U11( i I61i)lIREDF(/RINIPh'.('11()\5-PLEASECU,L(209)953-7697 <br /> DEPARTMENT U E O?7NLY <br /> Application Accepted By Date Area q q Employee ID# / <br /> Grout Inspection By Date1211 3 LJ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ln5pection By Date Constructed Well Dept ft <br /> COMMENTS /V LtL1.I .14 0a i , - (ems+• <br /> PE SC Received Check <br /> Amount Date Permit/ Invoice# Well I <br /> Codes Info B h tted Service Request# <br /> jX -a t a s icy-k(PE1 <br /> -76 <br /> s� <br /> EIID0r3-0604)0T2022_4 /��^ �/ Pagr 1 or? Well/Pum wait O <br /> b �/(/D (A 3 <br />