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� 4 <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S /Q� CITY/ZIP f �5 3 m <br /> CROSS STREET Ik H (/ / R�_APN d U 3 r O O-I I PARCEL SIZE .YV LAND USE APPLICATION# o <br /> OWNER NAME t a u G! ['At- �1�jQ �^'[��� PHONE ,2o 71!�j9�0(/ ` y <br /> OWNER ADDRESS l(o(o H 3 l��U CITY/STATE/ZIP (QQ/ 1 C Y1 / ✓3`y - <br /> CONTRACTOR ,y`��( ���'jj /1� PHONE 7067 ZZ - 2 7157 <br /> � <br /> CONTRACTOR ADDRESS a Cny/STATE/ZIP VAi,1eq �ae�!u 'e <br /> a < _ <br /> SUBCONTRACTOR PHONE—T �✓�5 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 2S C-57 ❑ C-61 ❑ 7�T,/_ <br /> D-09 ❑ Other NUMBER AO/ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE . ;K Domestic/Private r Irrigation/Agricultural ❑ Industrial 7 Water Quality Monitoring F Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ;K New Well C Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells Soil Borings) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> -fftNew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method V Mud Rotary ❑ Air Rotary -1 Auger -1 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3gW ft Excavation /7 ;y in diameter ❑ Open Bottom � Gravel Pack/Gravel Size in diameter <br /> _1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_(e in Thickness/Gauge/ASTM Sched SnA-7 j ❑ Steel %Plastic 7 Stainless Steel 7 Other <br /> Grout Seal Depth 'Q pp ' ft ❑ Neat Cement(94 lb bag/5-10 gal water) td Sand Cement /D• 3 sack mix/7 gal water <br /> 77 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method A Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By A Driller i Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width-4(e—ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP g Submersible❑ Turbine ❑ Other HP 3 Pump Set ft Standing Water Level <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 /> itIINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date i Z.l Z'5r Area &A �.t� Employee ID# -Ilt <br /> Grout Inspection By Date I Z eV Z4 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date_S/ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ �y <br /> Codes Info B Cash Remitte Date Service Request# Invoice F 1. # <br /> ® r;9 2 4k'g '- lti <br /> sq� <br /> m V14 <br /> c',y qQ Jr <br /> A ,4 <br /> FN <br /> EHDO43-06 10/252021 Page 1 oU p loaded into Ac c e i a Well/Pump Permit <br />