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I r` 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(209t953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS to�/ 2, CITY/ZIP <br /> m <br /> D <br /> CROSS STREET APN ' oO PARCEL SIZE ` l LAND USE APPLICATION# V <br /> ch <br /> OWNER NAME l>(� �t-� 1 l O '�7 PHONE (n <br /> OWNER ADDRESS L CITY/STATE/ZIP <br /> CONTRACTOR ri• IISS /PHO'NE Za'! '327�3�2G <br /> OF <br /> CONTRACTOR ADDRESS rJoOt �o a CITY/STATE/ZIP G+'Gt <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STTATE/ZIP_f{(�. <br /> LICENSE i +C-57 D C-61 ❑ D-09 ❑ Other NUMBER L(D Z� - EXPIRATION DATE ZOLij <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private 0 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal Cross-Connection Repair 54iOt.Af, f6,AA--- <br /> ❑ New Pum ❑ Pum Replacement XPum Repair 0 Raise Well Casing `( <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in 0 Christy Box 0 Stove Pipe RECEIVPA <br /> PUMP I.Submersible0 Turbine ❑ Other HP l• S Pump Set ft StandinsPme eh,,,- ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect t(L the fellow n s: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, NY*U�yuctures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two p 1�'pgLurnestic, <br /> Agriculture, Industrial well,provide location of any water wells or surface water within 200' radius of propose'&NRNENT <br /> N1111I%it Ni 24 I101'R 1:\OTICI;REQUIRED IOR ISSPECTIOV'S-I'LE%SI�:(_�1.I.t2209)9�3-7697 <br /> E P T M E N T U S ON Y <br /> Application Accepted By Date Za Area LJ Employee ID#— <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermIV Invoice# Well ID# <br /> Codes Info 13V f FAS!4Remitted Service Request# <br /> 4M V I-Z-23 <br /> EHD043.06 04!07/2022 �� �.{�/ Page I of 2 Well!Punv Pennit <br />