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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 /> �`' , .^ to <br /> JOB ADDRESS bL ti Z' 1 CITY/ZIP , It ' m <br /> CROSS STREET APN�fI _V (4_. `,CEL SIZ6Z'' �LAND USE APPLICATION# <br /> ca <br /> OWNER NAME r ��"► ��Gr �PHONE <br /> OWNER ADDRESS e �� /,�� ,/y I CITY/STATE/ZIP 1 V ^ \ �/ n/�/'� <br /> CONTRACTOR `S. N� ��� i�f , ` I PHONE'LV� 1�(0 ' V 1yy <br /> CONTRACTOR ADDRESS 1 O 8W I—`—` O CITY/STATE/ZIP � XM b i L �C� <br /> SUBCONTRACTOR 1 PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTAT�E/ZIIPQ <br /> LICENSE XC-57 ❑ C-61 11D-09 11 Other NUMBERIN TAU1 o-i EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural D 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 )(New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ; Geotechnical #of borings <br /> L Out-Of-Service Well Cl Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Jel�lud Rotary ❑ Air Rotary L Auger ❑ Cable Tool ❑ Push Point Other <br /> Proposed Well Depth � ft Excavation - 12` in diameter ❑ Open Bottom *A Gravel Pack/Gravel Size in diameter <br /> Cond�,s <br /> ing in diameter / Cond ctor Casing Depth ft <br /> Well Casing DiameteThickness/Gauge/ASTM Sched� ❑ Steel KPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement e2o7f x/7 gal water <br /> ,P-Bentonite(20%solids) L I Other <br /> Grout Placement Method Ai2Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller F1 Pump Contractor F! Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick FR <br /> in ❑ Christy Box Stove Pipe 04 COOS <br /> orb <br /> PUMP ❑ Submersible[] Turbine 11 Other HP Pump Set ft Standingw ARTME� ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to tATfiff6wing 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 /> MINIM( M 24 IVA 11 XONAV E No "I I( 1': Ildta)t(m I IONS-M I-4'Sl:f tl.t.(2111)9S3-"('()- <br /> DEPARTMENT UnE�O LY 9 <br /> Application Accepted B r Date ! ' Area ` 9 Employee ID# / <br /> Grout Inspection By A Date ?'V� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMMENTS e— <br /> �•yw o' -e 1&,W. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> �qNk o 244 WPI0045290 <br /> V3,7/- i,S—s' <br /> `i3 92 76 NV <br /> EHD043-06 04/07/2022 Page I of 2 WeII/Pump Permit <br />