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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1l yy��� N <br /> �r' / CITY/ZIP c� /� m <br /> CROSS STREET &A, APN 007-1/N040 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME �11L&` KIP C PHONE Ie, y <br /> OWNER ADDRESS —v rr CITY/STATE/ZIP q <br /> CONTRACTOR V I��3] PHONE v <br /> CONTRACTOR ADDRESS L CITY/STATE/ZIP <br /> SUBCONTRACTOR is PHONE 2! 3 1 ZL�' <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 37n(?s EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/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 WORI II ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 'Kew Pump <br /> Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> IlIZ'Gew Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud to ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth It Excavation 1?_1 in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conducto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter t6 in Thickness/Gauge/ASTM Sched'L,013 ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /2C> ft ❑ Neat Cement(94 lb bag/5-10 gal water) { and Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodAgr:Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width:�;_/ ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP submersible❑ Turbine ❑ Other HP= Pump Set It Standing Water Level 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 USE ONLY <br /> Application Accepted By Date /22 Area Empl/�s <br /> Grout Inspection By �H Date 1L ❑ SPECIAL Well Per``mmi b <br /> Pump Inspection By Date ❑ WAIVER Receivbe4P ' 20 <br /> Soil Boring Inspection By Date Constructed Well Dep 2 ft <br /> COMMENTS kiE R()-- <br /> /NC GI <br /> _ �h <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By aj5h Remitted Service Reque t <br /> '/;&4 160 20 is' 22 'A) <br /> V3C!/ 04S r <br /> y392 <br /> EHD043-06 04/07/2022 Page I ort Well/Pump Permit <br />