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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY 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 / LY J, J OU L-✓��Az CITY/ZIP ��N ` �J m <br /> ` `^ r <br /> CROSS STREET /�{ APN ZZa7_Z 50"3(0 PARCEL SIZED'7t7 LAND USE APPLICATION# <br /> OWNER NAME <br /> ¢T/✓ C �''�—�- PHONE �? <br /> OWNER ADDRESS + - CITY/STATE/ZIP <br /> lllO�N Gc?� 9S3Z-a0 �+ <br /> CONTRACTOR '/// J/�E/�/ � I t- �-LL—s/� `C,�J l�� PHONE <br /> S/,,7% 0 11 Z 2 <br /> CONTRACTOR ADDRESS /�L� �� CITY/STATE/ZIP <br /> SUBCONTRACTOR / /�'/ �`t-�/K`J � PHONE <br /> SUBCONTRACTOR ADDRESS CITY//`STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER V - EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:)<Genera I Mineral/Coliform Bacteria (4391)C 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 *eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ 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 CONSTRUIETION <br /> Drilling Method Mud Rotta�ary/y�0 Air Rotary ❑ Auger ❑ Cable Too[ ❑ Push Point ❑ Other <br /> for <br /> Proposed Well Depth �) ft Excavation � in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched GL., ZC ; ❑ Steellastic ❑ Stainless Ste <br /> Grout Seal Depth I&V ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement P saZ7r117 gal water <br /> /11Bentonite(20%solids) ❑ Other RECEIVED <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Z Pump Set ft SMW4990ATMA <br /> Plot Plan R quirements: 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 /> ,NIINIiNU,NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> � [ DEPARTMENT USE ONLY <br /> Application Accepted By I��Gy��`" Date Var Area Employee ID# n6 <br /> Grout Inspection By //�� Date c L Z62-10 El SPECIAL Well Permit <br /> r/Pump Inspection By e Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construed Well Depth ft <br /> COMMENTS �,L'7►�5� 'rLjtirs/ dtl;/jJl/HC �j�/ss�!' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> zo LMT cf) i- o- V b 1 <br /> ya .aa <br /> �o Os� .cc7 - —210 MAW <br /> EHD043-06 04/07/2022 Page I of 2 upioaaea i n o Amccela.p Permit <br />