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t WELL/PUMP PERMIT <br /> 1 , <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 /> l Z6-6 Ali /� <br /> JOB ADDRESS / � ��r� CITY/ZIP ��(% !A� 4rt q m <br /> '/ C D <br /> CROSS STREET L: lna la ' Re- APN g05q- /�l-D(� PARCEL SIZE � LAND USE APPLICATION# o <br /> X <br /> �^ L <br /> OWNER NAME r 1�U PHONE_ YQ� 7B�- 5316 " N <br /> OWNER ADDRESS �j L-SZ 7BeAe Cr-e- -C le- act CITY/STATE/ZIP Lad" Ln CjSLyU <br /> . C <br /> CONTRACTOR ! /L/t,��t�/1 1�f L ,AFRO/NE 2Q! / 7 7i' 2-7s-7 <br /> CONTRACTOR ADDRESS Gy Sam fjf/G/ /Z CITY/STATE/ZIP / <br /> �L/�fl(�L� aje�l-72L. � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT <br /> Y/STATE/ZIP <br /> LICENSE -57 C-61 ❑ D-09 Ll Other NUMBER 10171071? EXPIRATION DATE 457 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) p <br /> A ka <br /> INTENDED USE K'Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characte <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Others <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical— EdqPjj s <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair "9CTMt OCNMFCO N7), <br /> New Pum ❑ Pum Replacement Ll Pump Repair ❑ Raise Well CasingFp'9Rr <br /> WELL CONSTRUCTION <br /> Drilling Method V Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 360 ft Excavation in diameter ❑ Open Bottom It Gravel Pack/Gravel Size TA in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_&_ in Thickness/Gauge/ASTM Sched Q 2 1 ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 260 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement /6 3 sack mix/7 gal water <br /> T <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By yDriller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pd(destal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP_ Pump Set__ZA6a ft Standing Water Level u 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 /> NIINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> C <br /> DE P A R T M E NT USE ONLY <br /> Application Accepted ByL�� Date 7 a7 as Area qQ Employee ID# 1 ttlnK <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By W4{-'pro Date zL Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Well a i&r 'W I S l/ j <br /> 77 1,IJG �r 10 6I A, L L Z <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By ash Remitted Service Request# <br /> 439L vel �sb Z <br /> L13`6 )YO ¢y�v <br /> 431 1 <br /> 43ga 7b <br /> 4393 <br /> a <br /> EHD043-06 10/25/2021 Page I of2 Well/Pump Permit <br />