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ti . <br /> l 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 11YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS .�/ CITY/ZIP Gr i !!tTJC�� � m <br /> CROSS STREET APN IT(-Z60 -el PARCEL SIZE l 7-1 LAND USE APPLICATION# a <br /> /� �f�n _ Cn <br /> m <br /> OWNER NAME / .4 �0 X '�7v PHON� N <br /> OWNER ADDRESS �q// ��,/',�,�p C/ �—� yCITY/STATE/ZIP j�q <br /> CONTRACTOR [���fY l� J Y�47tt' PHONE/��% < ;51'3 K!CD <br /> CONTRACTOR ADDRESS �L 70 !"�'Ll.�/✓/���)�N�j CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ;�,Ic-61 ❑ D-09 ❑ Other NUMBER yG ed_1G EXPIRATION DATE z <br /> DOMESTIC WELL SAMPLING:;KGeneral Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)❑ Arsenic(4393) <br /> INTENDED USE Aromestic/Private ❑ Irrigation/Agricultural D 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,�PfMud Rota ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth20ft Excavation 12— in diameter ❑ Open Bottom ALAravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C—L-741)l ❑ Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 'LxAD ft ❑ Neat Cement(94 lb bag/5-10 gal wafer) and Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodApumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller AbIllump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick .7r <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Z 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 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Q!9 ZOaFS Area 3 Employee ID#t.T <br /> Grout Inspection By Date 30 Z ❑ SPECIAL Well Permit <br /> Pump Inspection By ate ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS >b Zt AAf!�"YtGY ✓vol/aP S-0po{.0t �i✓'« '�' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> yy8'� ali�Izs 2 - I I G <br /> Dsr �' �7 •oa �Ila I 2Sm �mAl <br /> do'­fly T <br /> R <br /> OA qr N <br /> EHD043-06 04/07/2022 Page I of 2 Pump Permit <br />