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r WELL/PUMP PERMIT <br /> JAN JOAQUI,N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ^ , /CA-LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /V, 11� CITY/ZIP � Z � m <br /> JOB ADDRESS m <br /> � j <br /> CROSS STREET �� CJ I Dh APN ��3 J a3 Cj PARCEL SIZE / LAND USE APPLICATION# <br /> OWNER NAME r� /'`/�L/� �T PH0NE �/'—�JN <br /> J ,, q to <br /> OWNER ADDRESS �/�yl� CITY/STATE/ZIP oRg <br /> CONTRACTOR ��. nil j'r�ljy��� PHONE / ? 3/1—moi�i!ln <br /> CONTRACTOR ADDRESS 2f7o <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR �� �10�T— N� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 -61 D-09 Other NUMBER 41,6SVL EXPIRATION DATE // <br /> DOMESTIC WELL SAMPLING:,!1 General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE __10bomestic/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 Boring(s) #of borings Geotechnical it 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 Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth (�ft Excavation /2— in diameter Open Bottom ArAGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 00 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> 1--votentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller lvump Contractor Other <br /> Concrete Pedestal Dimensions:Width_-7— 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 /> NIININILIM 24 HOUR ADVANCE NOTICE REQUIRED FOR 1NSPEC'FIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ,7 a °� °� Area Employ <br /> gw f �� <br /> Grout Inspection By Date ❑ SPECIAL Well Per rr <br /> Pump Inspection By Date ❑ WAIVER Received CEIVED <br /> Soil Boring 1Innspection By Date Constructed Well Depth II II 2 R M <br /> COMMENTS (=�1 >+ I �� U�JP�� j� Ie;,oe�1,1 i, �' ylj� 1R� AL1 . (J5k's <br /> (c(�� _ SAN JOAQUIN COUN <br /> PE Sc Received Check#/ Amount Dat Permit/ Invoice# HEALTH Well ID Permit/ <br /> Codes Info Ca h Remitted Service Request# <br /> �3F0 5) +)s <br /> g3-7x <br /> W 3"1 <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />