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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 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS fl z1f 13 it u -At AQ CITY21P AQc/� 95W.?o m <br /> CROSS STREET APN U'L 7'!/( /PARCEL SIZE/ 0LAND USE APPLICATION# <br /> OWNER NAME � / �7/G.� PHON�-EP%`(/ <br /> 1� —5�{7ZZ M <br /> OWNER ADDRESS CITY/STATE/ZIP ♦ � �7 L/' <br /> n L y <br /> CONTRACTOR � PHO/N� `� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTORPHONE <br /> SUBCONTRACTOR ADDRESS CITY/SpT.AATTEIZIP <br /> LICENSE -57 -61 ❑ D-09 ❑ Other NUMBER oJ/ 1 EXPIRATION DATE Z <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE *omestic/Pdvate i'o Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK WNew Well ❑ Replacement Well ❑ Well Alteration/Modification 0 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 /> V\Iew Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method ❑ Mud RoAir Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 11Other <br /> Proposed Well Depth �-ft Excavation /Y in diameter ❑ Open Bottom y ravel Pack/Gravel Size ' in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth / ft - <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 4CA,7- ❑ Steel Wlastic ❑ Stainless Steel [I Other <br /> Grout Seal Depth�ft 0 Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement 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 ❑ Driller Ypump Contractor q ❑ Other <br /> ❑ Concrete Pedestal DDimensions:Width—'7__ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 0 Other HP Pump Set ' ft Sta Sr' ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to I ems: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roa s mg we s, structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two prq%t1 pee 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)9SANJ AQUIN COUNTY <br /> EP R T M E N T USE O L YH TH DEPARTMENT <br /> Application Accepted By Date /telbC7,Z Area Employee ID# � <br /> Grout Inspection By Date l'L -6Z. 0 SPECIAL Well Permit <br /> Pump Inspection By Date TLk01,0'L� 0 WAIVER Received <br /> Soil BoringIns ction By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes In Cash Remitted Service Re uest# <br /> lj�_ M2 0- 1" _T <br /> 2 4< <br /> P 317 <br /> W POO JV15(0 <br /> EHD043-06 10/25/2021 Page 1 of 2 Well/Pump Pennit <br />