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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT i CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 155 3-IT LOVE +Irk rd _ CITY/ZIP �SL(M�� 95 3010 <br /> m <br /> m <br /> CROSS STREET S Dye, R, APN AQ 7 I 1 U 12 PARCEL SIZE LAND USE APPLICATION# Zito o <br /> OWNER NAME tC "1r(�,(ryG�W 1 �,y}n�.//I IP vr� PHONE I f)q�9) 'C 7Dn�G-570 y <br /> OWNER ADDRESS \J rl/'['�J ✓CA(-i tree rd. CITY/STATE/ZIP �5Lc,�,��(&)— /2 JQ )?- <br /> CONTRACTOR v r v� 1 t�I PHONE (;ka / & D—1 io 3' <br /> CONTRACTOR ADDRESS r CITY/STATE/ZIP peter 95 3ly c�F <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/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 ))New 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 Pq�lt, <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION IkAzuelvA <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger .Cable Tool Push Point ❑ Other <br /> Proposed Well Depth _JQ0 ft '.Excavation 1 01` in diameter l)Open Bottom ❑ Gravel Pack/Gravel Size Ctfidorr>R r <br /> )Conductor Casing in diameter / ConductoL Qasing Depth 60 ft <br /> hed <br /> Well Casing Diameter jQ in Thickness/Gauge/ASTM Sc a 1a ❑Steel ❑ Plastic Stainless Steel ❑j� AQU/N <br /> Grout Seal Depth 6_ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement <br /> jluentonite(20%solids) ❑ Other A TMre., <br /> Grout Placement Method XQpumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width:5--ft Length ft Thick 1� <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP X.,5ubmersibleo Turbine ❑ Other HP 4f_0_ 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 NOT!'r- I-EQU I 1 1 -'lr 11 <br /> �_-Pt EASE CALL(209)053 761'7 / <br /> �y.yy DEPARTMENT USE ONLY i"L <br /> Application Accepted I Lv Date 2- Zlii Area Employee ID# <br /> Grout Inspection By <br /> Date 2ECIAL Well Permit <br /> p <br /> Pump Inspection By _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Coristructed Well Depth ft <br /> COMMENTS ro V► ' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cas.h Remitted Service Request# <br /> F.HD043-0604/07/2022 � - Page I oft Well/Pump Permit <br />