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r <br /> E-MAILED <br /> 1 WELL/PUMP PERMIT <br /> - a5 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 <br /> NON-REFUNDABLE..//�PERMIT CnCALL 209 953-7697 FOR INSPECTIONS /fin EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS I7I f. S9Ybray <br /> 4E /� CrryrZiP I ppN / s3G6 975<i <br /> �1r- m <br /> CROSS STREET ' 44CK 7-0'"n- Xd• AP N' �d 3-d79-330I�CEL SIZE X-5 LAND USE APPLICATION# o <br /> OWNER NAME ZCK N <br /> DAEAv/ S /gl�A/G/t/ %!'ZVS� PHONE <br /> //n ` `� ' �?37 y <br /> /g <br /> OWNER ADDRESS ��� �r(r � r ! CITY/STATE/ZIP ,`1'ae", G} 9 s3(o(.-g7 o <br /> CONTRACTOR `„T " LEG�� /N PHONE BJ, <br /> CONTRACTOR ADDRESS / 3 o Y �fy e S r*- CITY/STATE/ZIP ' J5001I0&14 44 10/S�zy <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> � IP <br /> E/tZIP c QrL <br /> LICENSE SSC-57 ❑ C-61 ❑ D-09 11 Other NUMBER'/?�S 7 7 7 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)E Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring O:Soil Sampling/Characterization <br /> ❑ Public Water System N <br /> If different from Owner. Water System Name Contact Name or Phone Number Q <br /> TYPE OF WORK ew Well XReplacement Well ❑ Well Alteration/Modification ;k Othei-94. 1WAL1-- ISE/�y Caw 44,0-114rt oN <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> D New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method IK Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ob ft Excavation CI A.• in diameter ❑ Open Bottom if Gravel Pack/Gravel Size,,in diameter <br /> A Conductor Casing in diameter / Conductor Casing Depth O ft /� <br /> Well Casing Diameter JL in Thickness/Gauge/ASTM Sched ❑ Steel 2(Plastic ❑ Stainless Steel ❑ Other /� <br /> Grout Seal Depth r;bd ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack NT <br /> 11Bentonite(20%solids) 91;Other 66,V7-V.V r E� <br /> Grout Placement Method J111,Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> VU <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other .4d AA 1,J <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ftThick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑.Turbine D Other HP Pump Set It Standing Water Level <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 tines.For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MINIMU1NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By,/V/7b��"` Date `S-�i-taI Area Employee ID# <br /> Grout Inspection By L7� —>>--- Date p I I ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS &Z2 d k- <br /> -o <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info Byn ash Remitted Service Request# <br /> 3 / /Al-V <br /> EHD043-06 04/072022 /�I C�OC�T Z Page 1 of 2 Well/Puck Permit <br /> x.017 7 <br /> VOd <br />