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1 <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V CITY/ZIP 0-1 /6c;ID4_1 m <br /> J rnl�2 f1 f� D <br /> CROSS STREET IStAPN f ,d V / Q Q`7 PARCEL SIZE_3 LAND USE APPLICATION# o <br /> M <br /> OWNER NAME �7 PP)HONE_1� I/��� �-�7{U� C; <br /> CA <br /> OWNER ADDRESS / D Y� CITYISTATE/ZIP`✓Jne"1//�1.�0 q11DX <br /> CONTRACTOR aftI 1�) PPPHH/O[N,Ec� /�{-/�/ �j3� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP '-J/(�G1Li7/ -, 0J 1✓11.51/S <br /> SUBCONTRACTOR ldj�CA <br /> �� ��//jjPHONE //''��_6),? qqy ,g <br /> SUBCONTRACTOR ADDRESSll�t CITYISTATE/ZIP&*),(,Lq q"5" r l <br /> �} <br /> LICENSE C-57 Ll C-61 1-1D-09 E Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:)General Mineral/Coliform Bacteria (4391)>(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Pr vate C: Irrigation/Agricultural 11 Industrial 11 Water Quality Monitoring [: Soil Sam pling/Charactgp� <br /> E Public Water System A�� ��jj�� 1M7 <br /> If different from Owner. Water System Name Contact Name or Phone NumberglC <br /> TYPE OF WORK ,D�Vew Well E Replacement Well C Well Alteration/Modification l 1 Other <br /> E MonitoringWells #of wells E Soil Boring(s)s #of borings f ri1gs2O2 L <br /> O 9O IJ Geotechnical !1 <br /> E Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair O <br /> .KNewpump Pump Replacement E Pump Repair 0 Raise Well Casing �IVI//gQ , COU <br /> WELL CONSTRUCTON <br /> Drilling Method�1<Mud Rotary i. Air Rotary f 1 Auger 1 1 1 Cable Tool 1 Push Point 1 1 Other DEp�rM HT <br /> Proposed Well Depth f; ft Excavation in diameter 11 Open Bottom K Gravel Pack/Gravel Sizeb)--dt 4 in diameter <br /> 1 Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schedlto v ❑ Steel Plastic 11 Stainless Steel n Other <br /> Grout Seal Depth - ft C Neat Cement(94 lb bag/5-10 gal water) /)CSand Cement sack mW7 gal water <br /> t.! Bentonite(20%solids) i.: Other <br /> Grout Placement Method Pumped i. Free Fall I. Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller A Pump Contractor ❑ Other <br /> L Concrete Pedestal i_1Di ensions:Width :7 ft Length - ft Thick y <br /> in : Christy Box C Stove Pipe <br /> PUMP _- Submersible[] Turbine E Other HP �{ Pump Set___3 U ft Standing Water Level__L_Q 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 /> NUNIi►InI 24 HOUR ADVANCE NOTICE REQUIRED FOR LNSPECTIO:ti;s-PLEASE t_.�L j_"01 tki.i-iu <br /> �--y DEPARTMENT USE ONLY <br /> Application Accepted By Date y3 )bo� Area 3 Employee ID# ✓ <br /> Grout Inspection By 6�Nt 1 Date 2Z D SPECIAL Well Permit <br /> Pump Inspection By Date :1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS__ Xt�}ly�< .,1 i, :'P1 � lYI. Dr t'-;? �r„i f ✓ F'P f l 6c' 1 Y<:' <c tL G e I< <br /> PE SC Received hec Amount Pale Permit/ Invoice# Well ID# <br /> Codes Info B RemittedService Re uest# <br /> 3 ;Z� r - 41S,2 <br /> L13'7� J � <br /> 3r1 r) 170 <br /> EHll043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />