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'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 /> Q `` /f/J CALL 209)953-7697 FOR INSPECTIONS EXPIRES <br /> ,.11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /�% �/ d/'/// /"�.-� CITY/ZIP �/'���/�/1 �33 <br /> m <br /> � JJ /�/� 0/` ,/ <br /> CROSS STREET MVV (/T /�/�-�L�S �AyPNN `- PARCEL SIZE fis LAND UE APPLICATION# <br /> /'.'ted PHaAE�°`�� FIs'3 L y <br /> OWNER NAME � <br /> � �� 9 s330 <br /> OWNER ADDRESS CITY/STATE/ZIP rrP <br /> CONTRACTOR �///�I /c/� r •./ —PHONE <br /> /�9G <br /> CONTRACTOR ADDRESS F G-- CITY/STATE/ZIP V'�—"r <br /> SUBCONTRACTOR PHONE <br /> !�q I�6 CITY/STATE/ZIP OGC �tS� C.I/ �+✓(7 <br /> SUBCONTRACTOR ADDRESS PfS �GL <br /> LICENSELot <br /> -57 -61 ❑ D-09 ❑ Other NUMBER I EXPIRATION DATE 1AP1 2 <br /> DOMESTIC WELL SAMPLING:Y.General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Atomestic/Private ❑ IrrigationlAgricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK jb/New Well ❑ Replacement Well ❑ Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION 1f I Q <br /> Drilling Method ' Mud Rota!/ Air 'Rotary 0 Auger ,❑ Cable Tool [3 Push Point 0 Other <br /> Proposed Well Depth Excavation � in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Con uctor assn in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in lckness/Gauge/ASTM Sched 4�� 0 Steel lastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Benton'a(20%solids) 0 Other <br /> Grout Placem t Method umped 0 Free Fall 0 Other 0 Retardant./Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ;L-Pump Contractor 0 Other <br /> 0 Concrete Pedestal❑D ensions:Width ft Length ft Thick <br /> in 0 Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP !' Pump Set Q' ft 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 lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Fes" Date Area 3 Q Employee ID# 57— <br /> Grout Inspection By ate ❑ SPECIAL Well PermitA/� <br /> Pump Inspection By4 Date ❑ WAIVER Received PAYeft- /W 7� <br /> Soil Boring Inspection By Date Constructed Well Depth • / <br /> COMME/NTS Q• - •'N bo . Ww. i t A;10 7o 210 <br /> UEC <br /> 17-f 5 <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# E JDAQp�� # <br /> Codes Info B Remitted Service Request# <br /> THD <br /> 3 C2 .41D <br /> 3 Qd o s -� - -2 2-6 0 3 <br /> EHD043-06 04/07/2022 Page I of 2 n �/I/'t ( n'' (\WWeell/Pump Permit <br />