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4 <br /> 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 / L/ S /`�L� / CITY/ZIP ` I0 0 1 m <br /> CROSS STREET lu`I APN /3✓ l]D 1 PARCEL SIZE LADIIySE APPLICATION#�/ A <br /> OWNER NAME TTT`� PHONE � � �"�?� N <br /> OWNER ADDRESS Alnf CITY/STATE/ZIP <br /> CONTRACTOR PHONE 3 <br /> (jy 3 )� <br /> CONTRACTOR ADDRESS I i 1 CITY/STATE/ZIP /�/ii�� QS I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE y1C-57 C-61 1 D-09 i Other NUMBER / 7 f EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:*General Mineral/Coliform Bacteria (4391)ADibromochloropropane (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 eLdVew 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>.< Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth Lft Excavation in diameter Open Bottom i>6ravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casino Diameter in Thickness/Gauge/ASTM Sched 'yo_ Steel N<Plastic Stainless Steel Other <br /> Grout Seal Depth�l;o ft Neat Cement(94 lb bag/5-10 gal water) `Sand Cement -/T• �1 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 >4 Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 14 ft Length 62 ft Thick' <br /> in Christy Box Stove Pipe <br /> PUMP 5ZSubmersible Turbine Other HP ` Pump Set ft Standin 0QAQWN COUNDL ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to thA Wwes� PS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing <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 /> NIININIU11 24 HOUR-1D\',kNCL NO1 WE RLQUIRLD I-OR I.NSI'L(TIONS-11111,\SIC C kLI.(209)953-7697 <br /> DEPARTMENT USE ONLY { <br /> Application Accepted By ��� Date Area Employee ID# f <br /> Grout Inspection By r u ("S[d�llaY�L l�ul. Date pZZ f ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 13s0 l> 15927 -4 ZZ <br /> 3 78 0 0 2°I 22 OPOOL1311LA <br /> ' a�) 1 •# 1so D 3Z <br /> �I 9Ay7o <br /> EHD043-06 10/25/2021 Page I ol'2 Well/Pump Pcrmit <br />