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I 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 F05 I SPECTIONS EXPIRES 1 YEAR FRLIOCIAOM DATE ISSUED CA <br /> ADDRESS O CITY/ZIP <br /> - <br /> m <br /> � <br /> D <br /> CROSS STREET U LKAPNav— PARCEL SIZE LAND USE APPLICATION# o <br /> /,/� m <br /> OWNER NAME 1 /`�O A _ PHONE 7 O tJ — Clio <br /> tin, <br /> OWNER ADDRESS CITY/STATE/ZIP G �J <br /> CONTRACTOR y� I PHONE �y/,/�� ,JG�. �' <br /> CONTRACTOR ADDRESS � I c O�9 CITY/STATE/ZIP d �_ d& {/l.�(// <br /> SUBCONTRACTOR PSG PHONE 2/ ` <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ham+ �t 3 <br /> LICENSE �-57 ❑ C-61 [ID-09 [I Other NUMBER <br /> 7/vTE 6� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/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 ew 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 /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Xlud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3.1�;J ft Excavation in diameter ❑ Open Bottom A<Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft I <br /> Well Casing Diameter,,J§ in Thickness/Gauge/ASTM Sched T-M ❑ Steel pwlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth :2= _ft ❑ Neat Cement(94/b bag/5-10 gal water) N.6and Cement_/01 3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other DAVMc��r <br /> Grout Placement Method V Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By >6riller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete P destal ❑Dimensions:Width ft Length ft Thick rrl_52 <br /> in ❑ Christy Box ❑ Stove Pipe LUL <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing WateBAN UIN COIF <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the follgiggTµltp T N <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 2001 radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEP RTMENT USE NLY �J <br /> Application Accepted By - Date ?/�/ Area Employee ID# r/�. <br /> Grout Inspection By t~ C Date Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By D _Constructed Well Depth ft <br /> COMMENTS IJ el I 10 C a i-d 'h �"'� M✓ I <br /> Iv NAt"- <br /> PE SC Received Check#/ Amount Perniltl <br /> Co es In o B Cash emitted Date Service Request# Invoice# Well ID# <br /> �E7 Z ti 2 4 1 <br /> SZ� Z <br /> v 11 <br /> d <br /> EHDO43-06 10/25/2021 Page 1 of 2 Well/Pump Permit <br />