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EMAILED <br /> 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 C�QALr1L1 209 953-7697 FOR INSPECTIONS tl ,EXPIRES r1`YEAR <br /> ('FROM <br /> p`DATE ISSUED <br /> JOB ADDRESS [^/ "/ / 1 1"i �11 �1` 1 "� ,Q CrTY/ZIP I�AQ41 1 Cc\ 01✓I% 11�/ b�yy <br /> ';CROSS STREET—'I V�C��1yI� I M=APN / l 24 - '0 VR PARCELSIZE ll •� LAND USE APPLICATION# A <br /> ':OWNER NAME 1 PHONE 1/0.1 �y U q U(V 0-0 <br /> '.OWNER ADDRESS ✓/Anl `� O,I V`�(�) t'U\' CITYISTATEIZIP <br /> 'CONTRACTOR u\ 1 1� `� P(�H/O�NE <br /> CONTRACTOR ADDRESS „'1 1 1/ �/�"J Cr YISTATE/ZIP <br /> i <br /> I <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP ?,{1 <br /> LICENSE C-57 LiC-61 D-09 Other NUMBER 17- EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:x Genera I Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesticJPrivate Irrigation/Agricultural CJ Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> _ Public Water System <br /> If different from Owrer. '.'Dater System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well L Replacement Well Well Alteration/Modification :: Other <br /> Monitoring Well(s) #of wells Soil Borings) a olborings Geotechnical r or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump C.1 Pump Replacement Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rota Air Rotary Auger Cable Tool Li Push Point D Other <br /> Proposed Well epth Z�� ft Excavation - Ill' in diameter ill Open Bottom It Gravel Pack/Gravel Size —in diameter <br /> Conductor Casing in diameter / Conductor Casing DA-Ih ft <br /> Well Casing Diameter-\L in Thickness/Gauge/ASTM Sched Lo o steel lastic Stainless Steel Other <br /> Grout Seal Depth '1�� ft L Neat Cement(94 lb bag15-10 gal water) _I Sand Cement sack mix/7 gal water <br /> '�,Bentonitq(20%solids) I Other <br /> Grout Placement Method Pumped ❑ Free Fall C Other Retardant/Accelerator(name) <br /> --- -PEDESTAL InstalledInstalled By Driller r Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ftThick <br /> Christy Box Stove Pipe <br /> ;PUMP Submersible- Turbine Other HP 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, stater 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,pro%ide location of any water wells or surface water within 200'radius of proposed well. <br /> MININIL NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPFCTIONS-PLEASE:CALL t209)953-7697 <br /> E P ART ME N T US <br /> O L Y I <br /> Application Accepted By Date / IE � Area 1.9 1? Employee ID# L <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received PAY <br /> Soil Boring Inspection By Date Constructed Well Depth Nr <br /> COMMENTS 1jP.,V ft/ <br /> e _- <br /> If <br /> PE SC Received Check#! Amount Date Permitt Invoice N Well ?Q <br /> Codes Info By Cash emitted Service Request# <br /> 113G& lee 21 25 Pt 25 - Z 2,A Z. E �N <br /> Or.o.ENT <br /> �1hF T <br /> FHD003-0604/07/2022 2D5t�i o�Ipage <br /> 'f Z Uploaded into Acc.ela. w�r°,�„�r�m,i, <br /> CC <br />