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*/-_411T 3�97 X -�Jzl-v5o7.-,0-4 <br /> 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 / I CALL 209 �9g53-7697 FOR INSPECTIONS /E/X,PlI,RRESj1 YE,AyRJ FROM DATE ISSUED <br /> JOB ADDRESS /GSD/ a �'%J. lDi4Du IrY'-!L CITY/ZIP <br /> / ^� _ m <br /> CROSS STREET `�l�L -�� G� r�// I APN /a!5 AL2,- �7PARCEL SIZE�AND USE APPLICATION# A <br /> OWNER NAME !/ /C/1/�j�/ /L /�� L.fJ� /J� � � �— PHON� <br /> OWNER ADDRESS 4,,Or R11n, CITY/STATE/ZIP <br /> CONTRACTORyy/C �y S"� PHONE�,J/.;vr f <br /> CONTRACTOR ADDRESS �z� ��� j /!�_J CITY/STATE/ZIP <br /> SUBCONTRACTOR A< ///(� �%/!��/r/� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE//ZIP 7 <br /> LICENSE -57 C-61 ❑ D-09 ❑ Other NUMBER (44;e8-)6 EXPIRATION DATE I 3 p 3 <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)C_ Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System PAVM T <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ywReplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of boi'M <br /> [I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 'f a-t O 2 2 22 <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing SAN JOA NTY <br /> WELL CONSTRU TION ENVIRCINMEN <br /> Drilling MethodyMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other HEALTH DEPART&ENT <br /> Proposed Well Depth 3Z 4 ft Excavation 1-7— in diameter ❑ Open Bottom pVGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter I Thickness/Gauge/ASTM Sched G� ElSteel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Y 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 SetZZA(Z ft Standing Water Level 1W — 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 /> M[NIAll N1 24 HOUR IOW ANCL N01L RLQUIRI-:U FOR INSIIIJ I IONS-PI.E_ASE(Al 1 (209)9;;3-7697 <br /> DEPARTMENT USE ONLY <br /> C <br /> Application Accepted By Date t a Area / Employee ID# _ <br /> Grout Inspection By LO Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 2-51/�t„� j LY��� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS [;KIsf1r1C.. Well CA0,,,� 1. ?' i.[Y1(ey- nth✓Y�t <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info I y Cash Remitted Service Request# <br /> %2 �I;i, n <br /> 4 <br /> EHD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />