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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 <br /> /CALL (209 953-7697 FOR INSPECTIONS _ EXPIRES 1 YE R FROM DATE <br /> -ISSUED <br /> ( <br /> JOB ADDRESS L "I T� h IY1 Y CITY/ZIP C I L s� Z 9 'D Z Z l <br /> f D <br /> CROSS STREET C�t J A "" APN ��� 0 J i"I• PARCEL SIZE_ LAND USE APPLICATION# o <br /> m <br /> OWNER NAME �,$(/J/Z�s ��� V� PHONE �1 `'� �' / N <br /> OWNER ADDRESS ►��I� 111 <br /> J//��J ) CITY/STATE/ZIP �1 <br /> CONTRACTOR O C ot r° i'� PHONE <br /> CONTRACTOR ADDRESSL/ U-y��[////�j'"+�`' n/ Y.`� <br /> Jr` � CITY/STATE/ZIP <br /> SUBCONTRACTOR z /" LT C6 Z"'-S r r � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> � <br /> LICENSE 3<C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER / ,j-3PS EXPIRATION DATE � <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private 0 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 Flew Well >CReplacement 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>�,,Mud ttpry ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 7490 ft Excavation 17- in diameter ❑ Open Bottom 9 Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GauYe/ASTM Sched 'LO"D ❑ Steel XPlastic ❑ Stain ess Seel ❑ Other <br /> Grout Seal Depth!7.a() ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Ilif Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contract r ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ 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, 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 A <br /> Application Accepted By Date Ci' 13- Z 3 Area 04 k Employe # /r 6- <br /> Grout Inspection By 46NA Date 1A 23�' -7 C SPECIAL Well Per <br /> Pump Inspection By ate �Zj�'` ` � Ci WAIVER Receive <br /> Soil Boring Inspection By Date Constructed Well Depth C <br /> COMMENTS X22 <br /> 01 <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# O� # <br /> Codes Info By Remitted Service Request# <br /> t�"' 9.18.23 <br /> ost UI WV00440RI4 <br /> R L >T'' <br /> -44 - <br /> EHDO43-06 04/07/2022 Page 1 of 2 %k c l l I Pump Permit <br />