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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 ' CALL 209)9/53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM <br /> >DATE ISSUED <br /> JOB ADDRESS 1 <br /> `?1z <br /> Z/ 1R y X0 CITY21P ` -cz <br /> J� l,` D <br /> CROSS STREET En Y�J f APN 6117._!?l-eZPARCEL SIZE)rlZ LAND USE APPLICATION <br /> �#{_j �/ A <br /> OWNER NAME / e�.} PHONE <br /> �- Al —5,1 /1 uN <br /> OWNER ADDRESS • CITY/STATE/ZIP QAP73: ynk S!i <br /> CONTRACTOR PHON e� 95�Z--� <br /> CONTRACTOR ADDRESS 21ZO <br /> CITY/STATE/ZIP 451J* � ,�L�y� <br /> SUBCONTRACTORPHONE <br /> a <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP , <br /> LICENSE 57 61 [ID-09 ❑ Other NUMBER 06/ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE *omestic/Private 0 Inigation/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 VNew Well D 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 CONSTRUdTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth /-ft Excavation I JV- in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth / ft <br /> x <br /> Well Casing Diameters in Thickness/Gauge/ASTM Sched 4✓LZ.L ❑ Steel Wlastic ❑ Stainless Steel D Other <br /> Grout Seal Depth__2..JM ft ❑ Neat Cement(94 Ib bag6-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xpump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine D Other HP Pump Set ft Sta I°ME ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect tog , ems: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roa xis mg we s, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from twoprQpt lego Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius o r e <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9Sf NJMQUIN COUNTY <br /> EP RTMENT USE O LY H THDEPARTMENT <br /> Application Accepted By Date */ 9 Z Area Employee ID# <br /> Grout Inspection By Date (ti 7i Z ❑ SeECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In cion By Date Constructed Well Depth ft <br /> COMMENTS <br /> \R1L <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> 2 4 <br /> WPOO43157 <br /> W ' <br /> EHDO43-06 10/25/2021 Page I of 2 Well/Pump Permit <br />