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E ILED <br /> 1C WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA7.ELTON 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 ADD RESS ZJQ CITYIZIP tit L l/� r�tr <br /> � 22J -A0 D�t AR D <br /> CROSS STREET t,'\ 'V APN PARCEL$lZE LAND USE APPLICATION# A <br /> M <br /> (OWNER NAME I PHONE w <br /> OWNER ADDRESS 1�/ J r ,c CITY/STATE/ZIP,Qlrl( tbq 111J41,70 <br /> r/ <br /> (;CONTRACTOR 1 ( I N PHONE _/�1 :JL�� 'CIqt2-16 <br /> 'CONTRACTOR ADDRESS Crry/STATE/ZIP n WAD 6A <br /> le;-_31i7 <br /> .SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STA <br /> T <br /> E/ZIP G1� <br /> (LICENSE C-57 C-61 D-09 Other NUMBER ^ W EXPIRATION DATE�-1 !J V• Z'7 <br /> DOMESTIC WELL SAMPLING:X,General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDEDUSE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System T <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well N<Replacement Well _ Well Alteration/Modification -- OtherD <br /> Monitoring Well(s) #of wells Soil Boring(s) 4 at borings __ Geotechnical---�►,x of bon 8 �J <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair �1pgQU,N 5 <br /> New Pum Pum Replacement Pump Repair Raise Well Casing <br /> 'WELL CONSTRUCTION <br /> Drilling Method i Mud R=4 ) Air Rotary Auger Cable Tool - Push Point Other �. <br /> Proposed Well epth . ft Excavation '''1 in diameter Open Bottom .Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter/Conduct r Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ILN ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(201/6 solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box Stove Pipe <br /> PUMP ❑ Submersibles_. 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, dater 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 /> NIINI.NIE11 24 ItOUR AUN ANCE NOTICE REQLIRED FOR INSPE(TIONS-PLEASE CALL.(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> �jQ� <br /> Application Accepted By may/ Date X27� Area Employee ID# <br /> pO <br /> Grout Inspection By /!/ Date 1 13175 C SPECIAL Well Permit <br /> Pump Inspection By Date E WAIVER Received <br /> Soil Boring Inspection E3y Date Constructed Well Depth ft <br /> COMMENTS a' LL <br /> /r Se t e_ <br /> st a_ �Gca� a•. t4?t. toot c4 c <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well IDS <br /> /Sb 2 m <br /> /� e'o <br /> ERD°31-06 0/01l2022 �,c077Ao�-oo P `'°rZ U p I oad ed into Acce'�a Pum,a <br />