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• <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /J� <br /> � / I Ln <br /> JOB ADDRESS �/L �iv��il A A-IL CITY/ZIP L:a-( l 1. j , m <br /> CROSS STREET 1h ,APN.)V] �' V I PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME M ��''V� I� C-n, ✓-'✓� PHONE ')�1 `C <br /> OWNER ADDRESS IC I1�' r CITY/STATE/ZIP <br /> CONTRACTOR V l 1 �� 111 1PHONG IL '/ � I <br /> CONTRACTOR ADDRES4 - J446 , CITY/STATE/ZIR 1 y/i 1([ 6 Vl� — <br /> SUBCONTRACTOR ( ✓ PHONE <br /> SUBCONTRACTOR ADDRESS (CITY/STAT/E/ZIP If <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER l l EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral 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 WORK Zew Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings l Geotechnical #of borings <br /> 11 Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodX Mud to Air Rotary Auger, Li Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation _�� in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conduc r Casing in diameter / Co t% ng Depth ft <br /> Well Casing Diameter 7 in Thickness/Gauge/ASTM Sched. ' � ❑ Steel '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 /> YBentonite(20%solids) Cl Other <br /> Grout Placement Method 30umped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal LIDimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ 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 /> NIININlt it 24 1101, 11,4I)VA N(F No IR F RI.()l wrl)I'(Ilt I 10\S-I'l.I_XSL CAI I.2 9) <br /> DEPARTMENT US LY <br /> Application Accepted By Date /503IZZ- Area Employee ID# <br /> Grout Inspection By Date J 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date ConstructeWell Depth ft <br /> COMMENTS 3 g9 <br /> PE SC Received heck#/ Amount Permit/ 4 <br /> Codes Info B emitted Date Service Request# Invoic D# <br /> MF <br /> EHDO43-06 04/07/2022 Page I of 2 Well/Pump Permit <br />