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•r l� <br /> 1 WELL/PUMP PERMIT )6)S <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 209 953-7697 FO SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> PT JOB ADDRESS CITY/ZIP /- m <br /> m <br /> yy�� J D <br /> CROSS STREET �� APN O/3- 3 V_ l2 9C PARCEL SIZE / �•�v LAND USE APPLICATION# A <br /> OWNER NAME PHONE PHONE .� 7 S 7 vi <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> 1 <br /> CONTRACTOR & A Cent -ss t PHONE /yJ3/(7./^�Z 7Z� <br /> CONTRACTOR ADDRESS b -7 CITY/STATE/ZIP <br /> • <br /> SUBCONTRACTOR `� PHONE L j /2- <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ✓�-57 C-61 ❑ D-09 ❑ Other NUMBER 3�7�d5 EXPIRATION DATE V�Z� <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(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 Nu <br /> TYPE OF WORK �ew Well ❑ Replacement Well Well Alteration/Modification Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical <br /> I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair NOV O <br /> ew Pump [I Pump ❑Replacement PumpLiRe air Raise Well Casing 'r <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other S E JQAQUIN QOU <br /> Proposed Well Depths ft Excavation in diameter ❑ Open Bottom OeGravel Pack/G Q1ZQA� ,._��diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft ul1 M <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM Sched O7 ❑ Steel <Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Dept' 160 _ft ❑ Neat Cement(94 lb bag/5-10 gal water) p�Sand Cement /01 � sack mix/7 gal water <br /> Bentonite(20%solids) Li Other J� <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By r Iller ❑ Pump Contract Other • t <br /> ❑ Concrete Pedestal❑Dimensions:Width ! ft Length ft Thick <br /> �in r' Christy Box ❑ Stove Pipe <br /> PUMP 'Submersible❑ Turbine I 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT US�?E NLY <br /> Application Accepted B Date �� 3 22— Area Employee ID#� <br /> Grout Inspection By Date ?��1_� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By_ Date Constructed Well epth 3J U ft <br /> COMMENTS A1dl�P >� ,®ii �"ES. t�"�• � / <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> 3(elo / D Zo 2. <br /> 3 0 ds/ /s pdD 2 <br /> 39/ ass o� <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />