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Docusign Envelope ID:03DA8FGC-8D65-4E6E-97B6-D7123150DO02 <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .JOB ADDRESS CITY/ZIP V tr m <br /> CROSS STREET 9-~ , 1 / D <br /> APN"� � RCEL SIZE LAND UStE'�A�PyP^1LIClATrIO�N#�� l � <br /> OWNER NAME '# ttI rr�� �j�I ,CLQ( (r ( r y(C r PHONE L k( � `'E D -L® m <br /> OWNER ADDRESS JLfK s'--3 ( +tet �IA)OL?d `- )V J) CITY/STATE/ZIP } r i�q�L I -e-4,,:,f{� <br /> CONTRACTOR yt �l e yoeA( I,,�r�, yr C I/jti PHONE <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 Ll C-61 ❑ D-09 L Other NUM13ER _/ !SPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE ''Domestic/Private i 1 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 IeNew Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 1_1 Monitoring Well(s) #of wells LI Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well a Out-Of-Service Well Renewal L1 Cross-Connection Repair <br /> Li New Pump il Pump Replacement [7 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method's Mud Rota Air Rotary Auger a Cable Tool 11 Push Point ; Other <br /> Proposed Well Depth__Lft Excavation in diameter Open BottomJ Gravel Pack/Gravel Size in diameter <br /> LJ Conductor Casing in diameter / Con ctor Casing[[Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched',��1�t _' Steel 5? Plastic a Stainless Steel Other_ <br /> Grout Seal Depthft 1 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ,X Bentonite(20%solids) I 1 Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller WrPump Contractor LI Other <br /> A Concrete PedestaDimensions:Width Z's ft Length 2• ft Thick <br /> in ❑ Christy Box L 1 Stove Pipe <br /> PUMP A Submersible F] Turbine I1 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 IIOt It ADVANCE;NOTICE RI:4}t IItED FOR INSPECTIONS-PLEASE CALL(209)')53-70()-t <br /> DEPARTMENT USE ONLY <br /> A1Application Accepted By Date �L/,��Z 9Z Area 3 Employee ID# 'Z e <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS D <br /> PE SC Receivede`ck# Amount Date Permit) Invoi47��# <br /> Codes Info By Ca—sh Remitted Service Request# S <br /> yyfoo 2-1 W a s 3 Cv <br /> Os( �� �� a 5 g o ti c <br /> q r ti <br /> ElID043-0604/07/2022 Page I oftUploaded into cce a Well/Pump Permit <br />