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9. <br /> I * r WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT U(A �/ CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ti7� � 'C CITY/ZIP M`/C, -DNy ' <br /> M <br /> CROSS STREET r APN PARCEL SIZ LAND USE APPLICA2TIO(N# <br /> COWNER NAME �"`N 1 L )x PHONE J 1 O <br /> OWNER ADDRESS q s& PL0� CITY/STATE/ZIP f✓� ``''• 1 913 2 Q Cl /' <br /> CONTRACTOR �C � /`� � O r f i` PHONE C e vl O~ <br /> CONTRACTOR ADDRESS-P 'O)c I L o CITY/STATE/ZIFt 0iy"_, V?Vc- to? <br /> SUBCONTRACTOR I {`1 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE &_57 F C-61 ❑ D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: XGeneral Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I l Irrigation/Agricultural C Industrial Ei Water Quality Monitoring L I Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well -! Well Alteration/Modification Other <br /> I 1 Monitoring Well(s) #of wells I: Soil Boring(s) #of borings [I Geotechnical #of borings <br /> I Out-Of-Service Well i Out-Of-Service Well Renewal 1) Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Wt j 1Air Rotary Auger, ❑ Cable Tool Push Point Other <br /> Proposed Well Depth ✓��� ft Excavation 12 in diameter I: Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Con uct r Casing Depth ft <br /> Well Casing Diameter &in Thickness/Gauge/ASTM Schee i Steel .fPlastic Stainless Steel Other <br /> Grout Seal Depthft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> `6entonite 0%solids) o Other <br /> Grout Placement Method XPumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1! Driller i! Pump Contractor I i Other <br /> Concrete Pedestal ::Dimensions:Width ft Length ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP G Submersible ' Turbine I i Other HP Pump Set ft 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 /> NIINI)11 %1 24 1101 R ADN `,A('F:AO"I I('F:RL01 IRLD FOR I\tiPlV I'IONS-I'I.F:ASE( kLI.(3119)953-7697 <br /> DEPARTMEN/TSE NLY ^C� J0:'4Application Accepted By Date Area ! / Emplo <br /> Grout Inspection By Date [ A10 ?,[Yl.'k. SPECIAL Well Pe( It <br /> Pump Inspection By Date WAIVER ReCeiv e ,7 6 <br /> Soil Boring Inspection By Date Constructed Well Depth%JO v <br /> COMMENTS yFgiRp� CC)� <br /> Ep <br /> PE SC Received (gteoM Amount Permit/ <br /> Codes Info By Cash F3emifted Date Service Request# Invoice# Well ID# <br /> 3W 80 Zo l Z2 <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />