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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 CALL 209 953-76997�FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2")6 T2 FAJ6 -1 Cto C.P l CITY/ZIP pLn <br /> /GL(0D/f !"r 95 3� � m <br /> CROSS STREET a ad _APN ad 3_ D y0- Il alp p <br /> D <br /> !n (� y PARCEL SIZE �• LAND USE APPLICATION# p <br /> OWNER NAME ��({�/l!/,I AID m <br /> / PHONE�D ?�� M <br /> OWNER ADDRESS �[Q�Dy3 S 7jde "Oeel CITY/STATE/ZIP,6,, <br /> CONTRACTOR �n�'j7 ��if�(/JGj le26 PHONE <br /> CONTRACTOR ADDRESS ///� �[ , �3 Z� CITY/STATE/ZIP__1/�Q�/ �/XJ/)i�s G�j3 95Zr <br /> SUBCONTRACTOR , <br /> PHONE <br /> (SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LLICENSE _ C-57 C' C-61 D-09 L Other NUMBER !e[7a70 EXPIRATION DATE / Q <br /> DOMESTIC WELL SAMPLING. eneral Mineral/Coliform Bacteria (4391) ibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑ Industrial '7 Water Quality Monitoring G Soil Sampling/Characterization <br /> E Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK A New Well Replacement Well C Well Alteration/Modification ❑ Other <br /> Monitoring Wells) #of wells a Soil Boring(s) #of borings -. Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /Mud Rotary C Air Rotary Auger -1 Cable Tool L, Push Point F. Other <br /> Proposed Well Depth 300 ft Excavation 12 �X in diameter ❑ Open Bottom ?f Gravel Pack/Gravel Size 3 in diameter <br /> Conductor Casing in diameter / 'Inductor Casing Depth ft <br /> Well Casing Diameter _ in Thickness/Gauge/ASTM Sched S4Z 7-t ❑ Steel yPlastic 7 Stainless Steel -1 Other <br /> Grout Seal Depth QO ft �J Neat Cement(94lb bag/5-10 gal water) 4Sand Cement &d-3 sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped :i Free Fall ❑ Other :j Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor !IOther <br /> Concrete Pedestal _ Dimensions:Width_ ft Length ft Thick <br /> in G Christy Box G Stove Pipe <br /> PUMP SubmersibleFj Turbine ❑ Other HP Pump Set U ft Standing Water Level o 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 2001 radius of proposed well. <br /> NIINIAIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> 1 <br /> Application Accepted ByAA Date i'2.l -A l Area 041 Employee ID# (` <br /> Grout Inspection By ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ' GrOwt <br /> 6 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice C 1D# <br /> 13d <br /> 3� r M�7 Qvi <br /> a> �l 2- l 25 y <br /> R c <br /> tir <br /> EHD043-06 10/25/2021 Page 10 2 Ncll/Pump Permit <br />