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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 /> JOB ADDRESS ", IPLA CITY/ZIP 0 m <br /> CROSS STREET f pp! APN,f f,Y`(Jr ) D-I PARCEL SIZE 3('/8 LAND USE APPPLICATTIIOnN(#� A <br /> OWNER NAME i/C �r PHONE"� J�f 1 ,7 o`I y <br /> OWNER ADDRESS VU (A G l W CITY/STATE/ZIP <br /> CONTRACTOR , 1'-�o t L Y PHONE t-' 0 <br /> CONTRACTOR ADDRESS W I �7, L�G� CITY/STATE/ZIP 1V" Utz `-(- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER L EXPIRATION DATE ` <br /> DOMESTIC ELL SAMPLING.)(General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 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 Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rot try ❑ Air Rotary ❑ Auger El Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom AGravel Pack/Gravel Size in diameter <br /> ❑ Conductr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sche qs�A. ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth I 11� ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Xi Bentonit (20%solids) Li Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Li Dimensions: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 /> 1INIblt ll-14 1101 R.%IM4 kN( 1,A01'1( E R1Ot I R 1 1)1,(?}2 I WNW, I'1 1'.%'s : 1.1 (Z09) <br /> DEPARTMENT USE ONLY <br /> �n <br /> Application Accepted By Date Area � � Employee ID# ri <br /> Grout Inspection By �A��111.f 5 Date A Iq 22 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil BoringyJ�Qspection By Date Constructed Well DeOFL ft <br /> COMMENTS l�lioI* 2- f+/� <br /> EIVED <br /> PE SC ReceivedECheck#/ Amount Da a PermiUInvoic���yy ell ID# <br /> Codes Info Bsh Remitted Service Re uest# ,rKl! 1 202�6E' r F� = #9 ao i2 2Z (f <br /> HEALTH <br /> S o \t 1 ENVIRO ENTAL <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />