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I <br /> y WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT s� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �G/ 9 /Y�'J 1 CITY/ZIP Z rl D 1 a` m <br /> 1 <br /> �T T D <br /> CROSS STREET G APN S f 3S D o ) PARCEL SIZE 5 LA`H�ONE XA1,SE APPLICATION#Q o <br /> OWNER NAME p P �'� �"O� CA <br /> OWNER ADDRESS y> CITY/STATE/ZIP <br /> CONTRACTOR L/6 PHONE ZJ <br /> 7� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP6Y 126 <br /> SUBCONTRACTOR PHONE _ <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIPLICENSE t,,C-57 C-61 D-09 11 �S/Other NUMBER 2:7'f EXPIRATION DATE {7 j <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 e-GVew Well [�7eplacement 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 Metho(1✓y' Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth3 g!2D ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casino Diameter,6'— in Thickness/Gauge/ASTM Sched ��s,;— Steel NicPlastic Stainless Steel P Other <br /> Grout Seal Depth_/`•o ft ❑ Neat Cement(94 Ib bagl5-10 gal water) YSand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ,J Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By >CDriller Pump Contractor ❑ Other <br /> Concrete Pedestal LiDimensions:Width 7-4 ft Length ft Thick <br /> in Christy Box ❑ Stove Pipe APR 2 9 20022 <br /> PUMP Submersible❑ Turbine Other HP Pump Set ft Standin@*htl49AQWN COUNTY ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to thA "we <br /> PS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existins ruc res, <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 2001 radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r��� Date 1 a y as Area Employee ID# f <br /> Grout Inspection By rrra u t (o 1 n rM�L 4ti , Date p ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 125 SA <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> -43-FO .. 0-0) 27 41SO7 2Z <br /> 378 190 O 2°I Z2 V`J L13Z <br /> 3g 1 so 1 HeON-3NIK <br /> W a � <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />