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,. E-MAILED O <br /> 1 WELL/PUMP PERMIT <br /> 3-acp•as <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2O9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Y 1� Vl <br /> 'Joe ADDRESS 1 1 C(TY/ZIP m <br /> D <br /> 'CROSS STREET l/I/{ ,1 fr�(L-l(�,�/,r, �j� ALP'N}1�,► '►�y/{� O PARCEL SIZE�' LAND USE APPLICATION# A <br /> OWNER NAME &—AIM I "V� o '� 1 `1V�.1 V( t � m PHONE <br /> OWNER ADDRESS ( r ,1 CITY/STATE/ZIP <br /> CONTRACTOR 11A I K y�y1(ni1ry PHONE fgAY(i <br /> CONTRACTOR ADDRESS 1 1" l •/ v r"'S CrTY/STATE/ZIP <br /> SUBCONTRACTOR 4 PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATE/ZIP <br /> LICENSE �C-57 C-61 D-09 Other NUMBER wa? ExPIRATIoN DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omesti rivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owoer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well Well Alteration/Modification - Other <br /> Monitoring Well(s) 9 of wells :7 Soil Boring(s) a of borings Geotechnical a or borings <br /> Out-Of-Service Well Out-Cif-Service Well Renewal Cross-Connection Repair <br /> _ New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rot Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation 11 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mrxi7 gal water <br /> '�'Bentonite(20%solids) Other <br /> Grout Placement Method Pumped . Free Fall 'I Other Retardant/Accelerator(name) <br /> finPEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length It Thick <br /> Christy Box Stove Pipe <br /> PUMP Submersible)Turbine Other HP Pump Set ft Standing Water Level it <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: (:PS <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 No property lines. For Domestic, <br /> Agriculture,Industrial«'ell,provide location of and•seater"sells or surface"sailer Nithin 200' radius of proposed well. <br /> Nli\1�11, )1 24 HOL R AU`,A\CL NOI I(E KEQ1.IM l)1 014 I lU\>-pI.LAJF C ALL(20)9„-7b9 <br /> ^DEPARTMENT US ONLY ,s <br /> Application Accepted By � `'v ` Date 3 ZI Z� Area t7 Employee ID# <br /> Grout Inspection By Date 2 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 7t <br /> COMMENTSC1VQNt (1(,qI OIP,roYh 0kgM N toy 12r,-' DINe a QramA At r 121ud i <br /> PE SC Received Check#/ Amount PermlU <br /> Codes Info B C h emi ed Date Service Request# Invoice# Well ID# <br /> ego sc,-- A?a5G 1 S Z 1 <br /> n � <br /> i <br /> I <br /> r H[HNillt•04 07:2022 <br />