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y <br /> " E ILED <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 <br /> 1 CALL 209 953-7697 FOR INSPECTIONS (E�XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS %GI'l I N\ l/I` I 1/ CITY/ZIP loN 1 yJ-7/Z0 N <br /> M <br /> /�'� �"�/�.11 (� bmyy <br /> CROSS STREET ] 'tr\V�] S Irt �A�P/N (21 Q, t 0� V 2-0 PARCEL SIZE'-Q) LAND USE APPLICATION# r p <br /> OWNER NAME pr a� S1'1 �'`i V`Vr `�`' PHONE //�' % CID <br /> N <br /> OWNER ADDRESS 11 -W ,Al CRY/STATE/ZIP M�k m m <br /> CONTRACTORMa�` I(JII I�I�I,IQ��N� II PHONE U CAS-2 2 q <br /> JA <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP �A Q r V 6t154,9-7 <br /> SUBCONTRACTOR `` I PHONE <br /> SUBCONTRACTOR ADDRESS ,C(rry/STATE/ZIP <br /> LICENSE C-57 : C-61 C D-09 Other NUMB �YER U' -U +/ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE omestic/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) a°f b°nnge Geotechnical p 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 epth `' ' ft Excavation in diameter L. Open Bottom f' Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor asing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched C Steel lastic Stainless Steel I Other <br /> Grout Seal Depthft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack rri gal water <br /> "�,Bentonite(20%solids) Other <br /> Grout Placement Method IlPumped Free Fall Other _; Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other_ <br /> Concrete Pedestal Dimensions:Width If Length ftThick <br /> iin 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 sells, 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 /> ill\1\Il;�l 24 HOUR ADl ANCE:NOIICE REQLIREU FOR INSPECTIONs-I'I.E:ASL(ALL I' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By AA,-. �— Date 1 1(DII Z 's Area Employee ID#� <br /> Grout Inspection By / !/ Date 3/1I1ZS C! SPECIAL Well Permitp <br /> Pump Inspection By Date _ f WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth <br /> COMMENTS V—kA,,c c^ b e J-r—v� I f' �.t� c�✓�. <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# N �q Well I <br /> i!b I -R5 A P a 5 0 1 Co 472q oN �o <br /> �R q� <br /> T <br /> EHDO43-06 04,07/2022 Page I of 2 q'cll r pump Pennu <br /> CC# 1�583b� Uploaded into Accela <br />