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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 CAL 209 953-7697 Fo SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �JOB ADDRESS =Ad) FTCITY/ZIP '�/I` m <br /> y� <br /> 9 D <br /> CROSS STREET APN ID/3.. 3 0— l Z y,�q PARCEL SIZE 1p w LAND USE APPLICATION# A <br /> /'/ m <br /> OWNER NAME / /�Vffta 1 PHONE F7 (� _, N <br /> OWNER ADDRESS n U CITY/STATE/ZIP 2 /y" (� �7 <br /> CONTRACTOR o_SS �� Y /PHONE J 3 /•��1 7L_5_ <br /> aCy 7 CITY/STATE/ZIP l�/o,),�6 )L/ t CONTRACTOR ADDRESS j <br /> SUBCONTRACTOR �•`� PHONE?.`7_1S SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �57 _ C-61 ❑ D-09 El Other NUMBER 3/2.A J EXPIRATION DATE 6— <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE X 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 ft <br /> TYPE OF WORKlew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> FIC <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical D <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Li Cross-Connection Repair A'Ot, O <br /> flew PumpPumpReplacement El Pump Repair ❑ Raise Well CasingNOV <br /> WELL CONSTRUCTION SAN J'AQUIN C <br /> Drilling Method _j Mud Rota a Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point Other E DU <br /> Proposed Well Depth—%? ft Excavation in diameter ElOpen Bottom OeGravel Pack/G i DP0Ar. _NTameter <br /> i I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM Sched-2—JO Steel <Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Dept' /00 _ft ❑ Neat Cement(94/b bag/5-10 gal water) Wand Cement IV. sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other l <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Iler r Pump Contract ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in Christy Box I Stove Pipe <br /> PUMP 4'$ubmersible 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USEf NLY <br /> Application Accepted B Date /1 43/ZZ Area Employee ID#)C- <br /> Grout Inspection By Date 9-;X-W23 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depths <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> VU-40 Ito Zo 2 WP <br /> 3 0 os/ is P60 Jq h 244 <br /> 39/ ass 00 <br /> EHDO43-06 10/25/2021 Page I of 2 Well/Pump Pemut <br />