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' 1 WELL/PUMP PERMIT <br /> SAN JOAQU!N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS J /�� CITY/ZIP / ` `' � y m <br /> CROSS STREET ,V (JI /��/�'�C S /AyPN �J �' PARCEL SIZE LAND U E APPLICATION# X <br /> OWNER NAME y <br /> rap C;A) 9 6-330 <br /> OWNER ADDRESS Av�A � CITY/STATE/ZIP A <br /> CONTRACTOR /I ,fUL/�/i'f/l/� y�/" •�� •�i > PHONE `6 1731 <br /> Q <br /> CONTRACTOR ADDRESS ` G /yam-CITY/STATE/ZIP ���`- ` 15 Z <br /> ��j211 L <br /> SUBCONTRACTOR �/ L � PHONE f� C� <br /> SUBCONTRACTOR ADDRESS 1/-/ O tels A�//J CITY/STATE/ZIP eTii CSC c,�/Q 763,1- <br /> LICENSE IC-57 61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:gGeneral Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/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 ew 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 Casin <br /> WELL CONSTRUCTION �I <br /> Drilling Method#Mud Rota Air Rotary [I Auger /❑'Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter;!� <br /> ❑ Con uctor asin r in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Ickness/Gauge/ASTM Sched 4�J ❑ Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> Benton'a(20%solids) ❑ Other <br /> Grout Placemdnt Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑D ensions:Width ft Length L ft Thickel <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP JpSubmersibleo Turbine ❑ Other HP Pump Set d 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By Date 3 ZezSs Area 3 Q Employee ID# c�T <br /> Grout Inspection By ate ❑ SPECIAL Well Permit ` <br /> Pump Inspection By to ❑ WAIVER Received PA,►�j� <br /> Soil Boring Inspection By Date Constructed Well Depth R r { <br /> COMMENTS -60 a•f •rN &V .k IIKI. A W1*09 <br /> o Z/o of. i.Kr a <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# JD,qQV # <br /> Codes Info By Remitted Service Request# E <br /> 3 C2 •00 4V6 <br /> 3 Qr, o 61 ka 2W 1( •� ti -2 2 3 <br /> EHD043-06 04/07/2022 Page I of 2 n 5 <br /> Well/Pump Permit <br />