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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT .`�x CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS • rz CITY/ZIP C/�/tit��?': m <br /> 7 D <br /> CROSS STREET AAPN t,,, `/0 PARCEL SIZE LAND USE APPLICATION# [/ <br /> OWNER NAME (�!,,- '1 w !�/ '` PHONE 17 7 J V 7 -3.7 <br /> OWNER ADDRESS ^ y/V/1 , CITY/STATE/ZIP <br /> CONTRACTOR 1'-V �/C� r2'4) /c/��-L�ilf !Y'l PHOONE3zv Y7Zr <br /> CONTRACTOR ADDRESS & rC7`, L CITY/STATE/ZIP <br /> SUBCONTRACTOR g/ze d.t PHONE <br /> SUBCONTRACTOR ADDRESS CITYY//STATE/ZIP <br /> LICENSE '<'57 [I ` <br /> 57 C-61 D-09 Other NUMBER -3 7,3fS 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 11 Cross-Connection Repair <br /> New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,)i;&udotary ❑ Air Rotary Ll Auger Ll Cable Tool [I Push Point 0 Other <br /> Proposed Well Depth O a ft Excavation A/ in diameter ❑ Open Bottom ,)f Gravel Pack/Gravel Size in diameter <br /> 0 Condu r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched2_a O ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth &() ft [INeat Cement(94/b bag/5-10 gal water) �.6and Cement A. ssaacckk�k_IZ I\yaWr <br /> [IBentonite20%solids) 11 Other r <br /> Grout Placement Method J-P—umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By .kDriller ❑ Pump Contractor ❑ Other 41 <br /> ❑ Concrete Pedestal❑Dimensions:Width_/ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP AR[Submersible❑ Turbine ❑ Other HP Pump Set ft Standing We L <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the folItN&WHdlfiR#XWFT <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 /> EPARTMENT USE ONLY L. <br /> Application Accepted By l/ Date j 3 20ZZ Area Employee ID# <br /> Grout Inspection By c Date��/6�20 2zZZ ❑ 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 par Permit/ Invoice# Well ID# <br /> Co Info ash Remitted Servic Request# <br /> it21 013 <br /> _ Z <br /> EHD043-06 10/25/2021 Page I of2 Well/Pump Permit <br />