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DOCUSIgb Envelope ID:G793664A-E4B3-4B47-BF38-799E265783B6 <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDA LE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln <br /> JOB ADDRESS W CITY/ZIP (,0/) l CJ m <br /> D <br /> CROSS STREET u �/7 J� &-W- APN�0 - 03 0-'&2PARCEL SIZE 142-LAND USE APPLICATION# ( 0 <br /> OWNER NAME cn <br /> C)n V 1 A PHONE -7 ` ;3 <br /> C vn <br /> OWNER ADDRESS 7` CITY/STATE/ZIP r� <br /> CONTRACTOR ( V PH'ON/E�p-Z�/j`� L ( /t <br /> CONTRACTOR ADDRESS" `' cx L`Ti(0 Q CITY/STATE/ZIP ij V) <br /> SUBCONTRACTOR U_1 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP cif <br /> LICENSE kC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER I U44�fQ- <br /> �EXPIRATION DATE L <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) ibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private LI Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 2 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 Well(s) #of wells ;I Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method yd Mud Rotary Air Rotary Auger {{ D Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth Lft Excavation 1 in diameter Open Bottom gavel Pack/Gravel Size in diameter <br /> H Conductpr nCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter SSL in Thickness/Gauge/ASTM SchedGbp_2A ❑ Steel k Plastic Stainless Steel Other <br /> Grout Seal Depth �Zn_L)_ft ❑ Neat Cement(94 Ib bag/5-10 gal water) LI Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method numped ❑ Free Fall _ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Il Pump Contractor =i Other <br /> i i Concrete Pedestal ;Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box Stove Pipe <br /> PUMP [J Submersiblel_l Turbine iI 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 /> NHNI W �l?-i Ht t V RL t ittf l}i(m' 1v'Vi i t 103\° , i 0`-4 € <br /> DEPARTMENT USE ONLY t1 <br /> Application Accepted By Date /� -2Area 7 Employee ID# <br /> Grout Inspection By /� Date ��(0——2�3 C SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 6/5. t Z2'0,7— C c rwi�a, /CI'�^aci7 P O"e 11,14- 100".R°141-a4 6eli ee, l c--d <br /> PE SC Received heck# Amount Permit] <br /> Codes Info B ash Remitted Date Service Request# Invoice# �/ D# <br /> Y_?Ae / 2 20l Z <br /> 39/ /sem Li Z3 <br /> �392 7!0 -zl L3 E Q N <br /> h0 FNr <br /> FN <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />