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f � <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 <br /> a PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS a9 M��� �z� � <br /> /l u ClW1zlP �r f 9 J M <br /> CROSS STREET <br /> APN a0e0yb0a PARCEL SIZE C�.Ga D <br /> / LAND USE APPLICATION# 0 <br /> OWNER NAME tl0`j ���Q��----�- M <br /> J �7 PHONE.2 y <br /> DOWNER ADDRESS 211 q A v e v <br /> i CITYISTATE/ZIP�(�r►�eCct C���3 7 <br /> CONTRACTOR qy�A � &r� r, 9 CG �+ <br /> PHONE fry0 ',5 7 f" ��J Ci7 <br /> S <br /> CONTRACTOR ADDRESS Ofr -c-f C-' ooi l-e XA CITY/STATE/ZIP 041JA4t-f- C g - 01 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE ❑ C-57 V141 ❑ D-09 ❑ Other NUMBER r -T S EXPIRATION DATE Z O aL 7j <br /> _ QJ2. <br /> DOMESTIC WELL SAMP ING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE V, DOMestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑ Public Water System <br /> 14 'Decent from Omer Water System Name I <br /> Contact Name or Phone Number I <br /> TYPE OF WORK 'New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings <br /> U Out-Of-Service Well ❑ Gtion Repair � Pusl`, <br /> ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair CC V,ED <br /> New PUm2 ❑ Pump Re lacement u Pum Repair <br /> WELL CONSTRUCTIO ❑ Raise Well Casin <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Sp O22 <br /> Proposed Well Depth _ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave V�/{��^ <br /> U Conductor Casing in diameter / Conductor Casing Depth ft �C 1T i DEL <br /> ❑ Steel ❑ Plastic ❑ I <br /> Well Casing Diameter_ in ThicknesslGauge/ASTM Sched PARTP,1ENT <br /> Stainless Steel ❑ Other Grout Seal Depth_ ft ❑ Neat Cement(941b bagl5-10 gal water) ❑ Sand Cement <br /> ❑ Bentonite(20%solids) ❑ Other sack mix/7 gal water <br /> Grout Placement Method ❑ Pumped U Free Fall ❑ Other —— <br /> ❑ Retardant l Accelerator(name) <br /> �PEDES�TALInstalled By U Driller ❑ Pump Contractor ❑ Other.❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> ❑ Ch isty Box Cl Stove Pipe <br /> PUMP � Submersible❑ Turbine ❑ Other <br /> HP Pump Set_WO ft Standing Water Level_r,�r 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 pyoposeu well. <br /> :cluNl,MUM 24 HOUR ADVANCE FOR INSPECTIONS-PLEASE CALL(209)DS3-769,1', <br /> DEPARTMENT USE ONLY �/ /,�/ <br /> Application Accepted By L j— Date Area Area ]l <br /> Employoo ID# <br /> Grout Inspection by Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS /V W g O 4 <br /> A +C L I G ina H r cs H t <br /> ------ <br /> PIE SC Received Check#/ Amount PermiU Info B Cash Remitted Date Ser rice Re nest# Invoice# Well ID# <br /> pSI S6 3022 WPO <br /> -- I <br /> I <br /> F1-ID043-06 ion5/2021 <br /> Pagclof2 Well Permit <br />