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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 CALL 209 953-7697 FOR INSPECTIONS EXFkIRE S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C4, 1 II7— CITY/ZIP Ji `0<5tl 9 Sd 9 Q m <br /> CROSS STREET <br /> Cd APcJy{ D <br /> AN St1 ' y' PARCEL SIZE f(��3�LAND USE APPLICATION# <br /> OWNER NAME (//W „ "�„ PHONE �s <br /> r <br /> OWNER ADDRESS LJ �� CITY/STATE/ZIP f <br /> CONTRACTOR �7 �: /�.1 C PHONE <br /> CONTRACTOR ADDRESSd CITY/STATE/ZIP L7-�^ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 r / Z <br /> LICENSE �-57 El C-61 El D-09 D Other NUMBER �3 EXPIRATION DATE 6 Z_3 <br /> DOMESTIC WELL SAMPLING.)(General Mineral/Coliform Bacteria (4391);yDibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/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 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ GeotechnicalJr <br /> � <br /> D Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �v/+ P® <br /> ,ff. lew Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well Casingc] <br /> WELL CONSTRUCTION .q <br /> N <br /> Drilling Method J MudAotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> FNV/AQU/N <br /> Proposed Well Depth �5!eft Excavation _ j t` in diameter ❑ Open Bottom JWGravel Pack/Gravel Size <br /> Conduc Casing in diamet / Conductor Casing Depth ft TM <br /> [IFNT <br /> Well Casing Diameter r in Thickness/Gauge/ASTM Sched 2 00 ❑ Steel tOlastic ❑ Stainle s Steel El Other _ <br /> Grout Seal Depth'L 0 a ft ❑ Neat Cement(94 lb bag15-10 gal water) Sand Cement 7y sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP tgrSubmersible❑ 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 /> MINIMU NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY �( <br /> Application Accepted ByDaleC/�- 1�en Date �O clot Area L / Employee ID# Fl�i►�� �� <br /> Grout Inspection By r n 6y4ti A'^'f1 Date_c L SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS r*`)yv11F5t c L)_:,-- O;iIyi <br /> PE SC ReceivedChe Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 3$© 0"'>-) o )S6 2,7- 0() <br /> 3(E 1120 4 y.51,O 1 Inl <br /> g3c,I II We00iq'35qq <br /> L3ria il6I kVOOLL3919 <br /> EHD043-06 04/07/2022 Page 1 of 2 Well/Pump Permit <br />