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.y <br /> n � <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 �t�, ICALLL((209)953-761197 FOR INSPECTIONS �yEXPI�RES 1i6YEAR <br /> ,FROM <br /> �yDATE ISSUED_ <br /> JOB ADDRESS L./VN�/�� t�1. CITYIZIP '` ' " �`� �� / _ m <br /> ��JJ yy D <br /> CROSS STREET 77O' <br /> APN /J'B( ��/D` �PARCEL SI LAND USE /) <br /> APPLICATION <br /> -?Z- 7 <br /> #/ I� <br /> OWNER NAME <br /> C PHONg // � l —�/ ; bJ u? <br /> OWNER ADDRESS CHITTY/STATEIZIP <br /> CONTRACTOR J Il,��'/ � !�!/� jEje�j�� �7�`,/7 " 5� �^"'�—�PHO/NE� f��/j�f���Q � <br /> CONTRACTOR ADDRESS .7 1210 GU1LL'-vim /zo CITY/STATE/ZIP – / / <br /> C � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 -61 ❑ D-09 ❑ Other NUMBER wagEXPIRATION DATE L <br /> DOMESTIC WELL SAMPLING:❑General 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 ❑ New Well replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Borings) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> kf�ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC ION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Wliravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-I(e— in Thickness/Gauge/ASTM Sched .,/— ❑ Steel ;Vlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /&V ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> �entonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ 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 ubmersible❑ 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 /> MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT U E ONLY <br /> Application Accepted By A)�' Date Lfl k- Areal Employee ID# J" <br /> Grout Inspection By NI-b`c.l Date I6'td-ay n SP Well Permit <br /> Pump Inspection By �� Date I WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth '�Zl <br /> ft <br /> 10� <br /> COMMENTS �/1 d l �1 <br /> AYMENT <br /> RECEIVED <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted, Date Service Request# Invoic T 1 4 ZQ U II <br /> C <br /> 4104 Z4 AN-40 1108 <br /> J,. ENVIRO MEN <br /> 05A Ty i(D 104 RP2.401109 AV LI_ 17h <br /> ERD043-06 04/07/2022 /`,�„ 16200 <br /> W20O Page 1 oft Well/Pump Permit <br />