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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 209 953-7699��7FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2 �9 I AZ &Z,�nt/I o- /Y/ CITY/ZIP��Peed '97 � N <br /> m <br /> CROSS STREET I� wI�►�J APN oa 3 i a o O6 PARCEL SIZE Jq j(- LAND USE APPPLLIC,AT`ION# rn <br /> OWNER NAME /� T ���T eS IPHONE <br /> OWNER ADDRESS C tn��,¢-c nl/ CITY/STATE/ZIP eM l pn 5 Cn �5 ZZ7 <br /> CONTRACTORrtlu IYl h iY)( PHONE 2�9 �7Z`` 757 <br /> CONTRACTOR ADDRESS r/{/ �ax I�2�/ CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE T <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 i C-61 ❑ D-09 ❑ Other NUMBER A017079- EXPIRATION DATE 15?- 31' 701-L <br /> DOMESTIC WELL SAMPLING:AI General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE X 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 7LNew 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 /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method A Mud Rotary ❑ Air Rotary i Auger ❑ Cable Tool ❑ Push Point Other <br /> Proposed Well Depth 3Lo ft Excavation /7 %z in diameter ❑ Open Bottom ?(Gravel Pack/Gravel Size PA�diaml 8 T <br /> Conductor Casing in diameter / Conductor Casing Depth ft ppC��i**i01iee� <br /> Well Casing Diameter_IA_ in Thickness/Gauge/ASTMSched r R 1-1 ❑ Steel .(Plastic ❑ Stainless Steel i Other REVEIV D <br /> Grout Seal Depth /� ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement 11j•7 sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other -�_ 2j 1$ 22 <br /> Grout Placement Method A Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> NTY <br /> PEDESTAL Installed By XDriller ❑ Pump Contractor i Other FNVIRQNMF 1 <br /> AL <br /> ❑ Concrete P destal❑Dimensions:Width ft Length ft Thick HFAI TH DEPAR IAENT <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP1,$-- Pump Set LZ- ft Standing Water Level Sys ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br /> potential sources of contamination,sewers or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT I l c F ONLY <br /> 7 � <br /> Application Accepted By Z Z— Date al a Area C Employee ID# <br /> Grout Inspection B -.'. Date pp. 1 �2L ❑ SPECIAL Well Permit <br /> Pump Inspection By Date'%�Sv ,1 � ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS } t ) i o 1 L <br /> L _ <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# (J <br /> Codes Info Cash Remitted P I Service Request# J <br /> 1390 Os 1 -f <br /> 3-7$ 180 ) r I OP Iva 3 _ <br /> L3el I 1S0 i <br /> EHD043-06 10/25/2021 Page I of 2 13 Z! L 0 Well/Pump Permit <br />