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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 />NUN-KEFUNDABLE PERMIT UALL ZUy W)J-/697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � � u A �/ / Q J� z CITYIIZII/P AQc /� ��? <br />CROSS STREET APN C%'L 7' !/( /PARCEL SIZE/ LAND USE APPLICATION #_ <br />OWNER NAME � '� � / N7/�`� PHONE ��`1) P%`(/ — { G(rj <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP -5-!Nt4� (/moi y��� <br />SUBCONTRACTOR{�{ �7J�/:.Lld�,/Fj PHONE <br />SUBCONTRACTOR ADDRESS CIIT45/18614 <br />Y/SpT.AATTE)IZIIP <br />LICENSE �C-57 %U-611 oJ` ❑ D-09 ❑ Other NUMBER /1 4 EXPIRATION <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE <br />TYPE OF WORK <br />Iguomestic/Private 'Irrigation/Agricultural ❑ Industrial <br />❑ Public Water System <br />If different from Owner. Water System Name <br />❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />,WNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(S) # of borings <br />Contact Name or Phone Number <br />❑ 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 ❑ Mud RoAir Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <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 oCA,7- ❑ Steel Wlastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth--,20,_ft ❑ 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 dump Contractor q ❑ Other 11 <br />❑ Concrete Pedestal ❑Dimensions: Width —7_ _ ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP --- jam_ Pump Set E .S y ft StaRAWE.*1 %35-" 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 Ing we s, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two prQ%1"le� Domestic, <br />Agriculture, Industrial well, provide Vocation of any water wells or surface water within 200' radius o <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL. (209) 9$if NJMQUIN 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 k 4 -6Z. 0 SPECIAL Well Permit <br />Pump Inspection By Date 'j'c�IJ'l.-©`t- 0 WAIVER Received <br />Soil Boring In�ction By - Date Constructed Well Depth ft <br />T <br />m <br />D <br />0 <br />0 <br />m <br />�MINIM, <br />. <br />UPS� <br />EED043-06 10/25/2021 <br />Page 1 oft <br />Well / Pump Pennit <br />