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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 (2209) 953-7697 FOR INSPECTIONS EXPIRES 11��YEAR FROM DATE ISSUED <br /> JOB ADDRESS ! � � le �� CITY/ZIP Aoe �/ ) J _ m <br /> /` / 7U APN ��(— �O D <br /> CROSS STREET "�� PARCEL SIZE Z LAND USE APPLICATION# <br /> OWNER NAME / /f4� /� �G PHONE-41 <br /> OWNER ADDRESS L �( /� + 6 CITY/STATE/ZIP <br /> CONTRACTOR � ��7 �—/VCR PHONE�F� <br /> CONTRACTOR ADDRESS !�� y(.� �v6 CITY/STATE/ZIP <br /> SUBCONTRACTOR Y` %� /L I��._/ � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE -57iC-61 ❑ D-09 ❑ Other NUMBER �!j V � EXPIRATION DATEA27 <br /> DOMESTIC WELL SAMPLING:)-( General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br /> INTENDED USE ornestic/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) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method VMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 2 ft Excavation — in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth •4T ft ❑ Neat Cement (94 lb bag/5-10 gal water) and Cement sack mix/7 gal water <br /> ❑ Bentonite (20% solids) ❑ Other <br /> Grout Placement Methodumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator (name) <br /> PEDESTAL Installed By ❑ Driller Apump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ��" ft Length ft Thick �► <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set /LV 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 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 /> iVl1NENIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date !y ZG Zs- Area Employee ID#i— <br /> Grout Inspection By Date ?7� �i ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construed Well Depth ft <br /> COMMENTS XA617%- � ,e We.&f�� e /I a/' SYjD-t et �✓'�rrw•% - <br /> lop, r <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> ly <br /> y t�S� � ` '' //7 •va all`! O � 25m I�I� <br /> R <br /> EHD043-06 04/07/2022 Page I oft Pump Permit <br />