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t 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 FR6m DATE ISSUED <br /> Li <br /> JOB ADDRESS ! t CITY/ZIP `�Z � m <br /> D <br /> CROSS STREET N. (-/iJf c/ APN 03L-77e)­ L17—PARCEL SIZE�i�LAND USE <br /> /APPLICATION# <br /> PHONE <br /> K�— <br /> OWNER NAME �/` 1 �, '�/� '/( <br /> OWNER ADDRESS L6J Y '- CCIITY/STATE/ZIP r5KV DyQ/"�/�-t��y� /�S <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS L(/ �/U�1L'D CITY/STATE/ZIP -157/11l <br /> SUBCONTRACTOR GY �� I�/�/�r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )CC-57 VO-61 ❑ D-09 ❑ Other NUMBER L S r- EXPIRATION DATE—//--?, 7 <br /> DOMESTIC WELL SAMPLING: J General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)..Arsenic(4393)ft <br /> - <br /> 4—A <br /> USE WDomesticlPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charan <br /> �ilyp <br /> ❑ Public Water System 8/d/-n <br /> If different from Owner. Water System Name Contact Name or Phone NumbeJ g, ' <br /> TYPE OF WORK VNew Well D Replacement Well ❑ Well Alteration/Modification ❑ Other t o2Z� <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical O �n g S <br /> C <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection RepairCTy MSN 7y <br /> ON OV <br /> ew Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingO�pA,gTT'q� <br /> WELL CONSTRUETION <br /> Drilling Method>dMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth zso ft Excavation 12 in diameter ❑ Open Bottom 'ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Gk%gV ❑ Steel AoPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller VPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP >OSubmersibleo Turbine ❑ Other HP Pump Set ft Standing Water Level <br /> Plot Plan R uirements: 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT <br /> USE O LY /v <br /> Application Accepted By Date < Areae ? Employee ID# <br /> \y Grout Inspection By Date 1 /I Z 3 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received 9( t <br /> Soil Boring Inspection By Date Constructed Well Depth �1S ft <br /> COMMENTS — . Gkr <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Request# <br /> 360 /0 A.,t y20 9 2m123 w wmy� �5 <br /> Y391 1 1 <br /> /tv2 5V6 w9QQ'4e <br /> EHDO43-06 04/07/2022 Page I of 2 Well/Pump Permit <br />