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ry • . r C) <br /> 1 ` J 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 23`to6 �, J C Ill k&r �AQ V& Ln <br /> ` ,/� n Q. CITY/ZIP m <br /> CROSS STREET ��i,L N© (/ ZV I ePARCELSIZE LAND USE APPLICATION# o <br /> OWNER NAME /6 /1%lri^I PHONE-7/ <br /> N <br /> OWNER ADDRESS c y / CITY/STATE/ZIP 2 U <br /> CONTRACTOR / '�A /'7 cS s P,.�ji{ j- t PHONyEJ� <br /> CONTRACTOR ADDRESS P�/u -769 <br /> CITY/STATE/ZIP If/IX0y 16ki }� <br /> SUBCONTRACTOR j[ � � t PHONE J ,2-7 s ISO <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ­iie57 ❑ G131 ❑ D-09 ❑ Other NUMBER�� / `� EXPIRATION DATE '2 <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 /> i:1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Aew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> I 1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical # -/�c <br /> i:igut-Of-Service Well Out-0f-Service Well Renewal ❑ Cross-Connection Repair <br /> Negw Pum El Pump Replacement Pum Repair El Raise Well Casing J C <br /> V <br /> WELL CONSTRUCTION S <br /> W 4W <br /> Drilling Method �t Iud Rotary Li Air Rotary 1:1 Auger Cable Tool 11 Push Point . [I Other E QU/tv <br /> Proposed Well Depth Excavation Excavation in diameter ❑ Open Bottom Y Gravel Pack/Gravel Size STH �11�r <br /> El Con dTuctorCasing in diameter / Conductor Casing Depth ft RTMEjy <br /> Well Casing Diameter_6_ in Thickness/Gauge/ASTM Sched 'L6 V oSteel Mastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth _ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> CI Bentonite(20%solids) ❑ Other <br /> Grout Placement Method/ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By > Driller ❑ Pump Contract C Other <br /> L1 Concrete P destal Dimensions:Width ft Length e ft Thick <br /> in ❑ Christy Box L Stove Pipe <br /> PUMP Submersible❑ 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 USE 9NLY <br /> Application Accepted By L/ Date �� �3 Area Employee IN tj A <br /> Grout Inspection By ev" Date /Z4-23 ❑ SPECIAL Well Permit <br /> Pump Inspection By '~ Date '2 ❑ WAIVER Received <br /> Soil Boring Inspect' n By Date Constructed Well Depth � ft <br /> COMMENTS LuG l�-_ ,K C-:. v� L,>0LrUAAe L_,, I✓ CD`s t <br /> PE Sc ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> l O O 02.023 wlpo D4waes <br /> J Y� (p�2$t23 WPCC(D�4foloto � <br /> 0 <br /> EHDO43-06 10/25/2021 Page I of 2 Well/Pump Permit <br />