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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 2/09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP �{'► r m <br /> Z + 2 D <br /> CROSS STREET APN j) J \ / PARCEL SIZE LAND USE APPLICATION# <br /> N <br /> OWNER NAME L �fG. PHONE !?!] ��— � � ? <br /> OWNER ADDRESS , CITY/STATE/ZIP <br /> CONTRACTOR X�LXCA'asS6�&J� PHONE <br /> J�Z Lt- -[1 <br /> 7&S' <br /> CONTRACTOR ADDRESS f �r/ / /79 CITY/STATE/ZIP [ 511 <br /> y �q y/( 1j0e_7 <br /> SUBCONTRACTOR PHONE �'7 I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 ❑ C-61 El D-09 ❑ Other NUMBER-32!v v S EXPIRATION DATE z'f' <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 Number <br /> TYPE OF WORK XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(vlud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ,J ft Excavation /2 in diameter ❑ Open Bottom t5bravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter,6' in Thickness/Gauge/ASTM Sched 21C Z ❑ Steel A<Olastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthlr)J ft ❑ Neat Cement(94 lb bag/5-10 gal water) >eSand Cement Z& sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick MYMFPJT <br /> in ❑ Christy Box ❑ 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 W64idk tke&2.3c-Ps <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, ex sting wells, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two pro. q 0NWtic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of prQMWARTMENT <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-I'LEASE CALL.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �C4 I°( Area D4k qA Employee ID# R L <br /> Grout Inspection By L ," Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3V��/'� <br /> ft <br /> COMMENTS V:0 I(- L0A.1c>Lg� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> LG �J �" %411(012-3 WPW44 53 <br /> gc) ( b X `' vb%02.3 wPmCD4y 5'4 <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />