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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 CALk(209)GIP3,4§l97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L Crry/ZIP <br /> / 9 D <br /> CROSS STREET r ) / N ^I oo PARCEL SIZE / / LAND USE APPLICATION# <br /> t <br /> OWNER NAME � - PHONEN <br /> OWNER ADDRESS 1 CITYISTATE/ZIP� P y <br /> CONTRACTOR �. <br /> �! / PHONE'' (W^ <br /> CONTRACTOR ADDRESS r CITY/STATEIZIP <br /> SUBCONTRACTORt 1 1 PHONE \ <br /> SUBCONTRACTOR ADDRESS r'�,.x.I Sj(4TEIZIP <br /> LICENSE C-57 O C-61 ❑ D-09 C Other NUMBE rt ) EXPIRATION DATE <br /> DOMESTIC WELLS PLINK: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private C Irrigation/Agricultural Cl Industrial U Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well C Replacement Well C Well Alteration/Modification ❑ Other <br /> s #of berm s <br /> ❑ Monitoring WellCBorings)_ ?!of borin9 s) #of wells Soil <br /> ❑ Geotechnical---�y� <br /> C. Out-OfServicWell C Out-Of-Service Well Renewal F1 Cross-Connection Repair <br /> C Pum New Pum Replacement C Pump Repair ❑ Raise Well CasingSq 2-920,27 <br /> WELL CONSTRUCTION �Nlr Q(1/ <br /> OUAI <br /> Drilling Method L' Mud Rotary L Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other NEq�TH CNMECA/ <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom L Gravel Pack/Gravel Size h'Ttp ' meter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft T <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel El Other <br /> Grout Seal Depth ft C Neat Cement(94 Ib bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) it Other <br /> Grout Placement Method ❑ Pumped C Free Fall C Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller C Pump Contractor U Other <br /> C Concrete Pedestal❑Dimensions:Width ft Lengthft Thick <br /> in L Christy Box C Stove Pipe <br /> PUMP Submersible❑ Turbine Other HP Pump Set ft Standing Water Level <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 /> NJINENIUNI J UR AD ANCE N01 ICE IZEQ ti :�R I.NSPLCTiC;,NS-PLEA S;: -;i i (203)'.'u-'/6:-'1 <br /> EPARTMENT U EpO.N <br /> Application Accepted By Date �o Z✓ Area Employee ID# <br /> Grout Inspection By _ Date 71 SPECIAL Well Permit <br /> Pump Inspection By -\ 1r t�L�� Date IJ u�Z J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heek#I Amount Permit/ <br /> Well ID# <br /> Date Invoice# <br /> C des Info B Cas emitted Service Request# <br /> gZ W o0 0 <br /> EH13643-06 04107,2022 Pogo 1 of 2 W dl!Pump P�7mit <br />