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EMAILE® <br /> 1 - a WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205 - (209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 r r ( CITY/ZIP ., el uv,, ; - i-Ir <br /> CROSS STREET �CtAPNl t CJ PARCEL SIZE v` LAND USE�APPLI(C�jAT�ION# `I A <br /> OWNER NAMEt�11V1�C TOe 1 `� I��i�L:3 PHONF�C�� <br /> OWNER ADDRESS CITY/STATEIZIP /� \ / �( <br /> CONTRACTOR l L�� .{ � �l �\' 1 l I 14� l PHONE ��/�l! `( U <br /> ( <br /> CONTRACTOR ADDRESS c—� F '`� t' CITYISTATEIZIP kV,Lth(Vl v 6 -4 4: 7 <br /> SUBCONTRACTOR I1� `y PHONE <br /> SUBCONTRACTOR ADDRESS C``ITYISTATE/ZIP <br /> LICENSE C-57 C-61 C1 D-09 Other NUMBER V ExPIRATION DATE 64 <br /> DOMESTIC WELL SAMPLING:,C Genera I Mineral/Coliform Bacteria(4391)XDibromochloropropa ne(4392) Arsenic(4393) <br /> INTENDED USE 'YDomestic/Private Irrigation/Agricultural L 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) u of borings Geotechnical � <br /> Out-Of-Service Well G Out-Of-Service Well Renewal Cross-Connection Repair E <br /> New Pump ! Pump Replacement I I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION s 202 <br /> Drilling Method )(Mud Rotary Air Rotary Auger I1 Cable Tool Push Point C1 Other �JO <br /> Proposed Well Depth ft Excavation 12- in diameter Open Bottom � Gravel Pack/Gravel IR <br /> �d 'W. <br /> ' Condu or Casing in diameter / Co cbrr Casing Depth ft TqC <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sche ��� Steel ..`Plastic _I Stainless Steel Other <br /> Grout Seal Depth_ eft Neat Cement(94 lb bagl5-10 gal water) I i Sand Cement sack mixl7 gal water <br /> X Bentonite(20%solids) Other <br /> Grout Placement Method&umped I Free Fall -- Other I I Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller D, Pump Contractor Other <br /> 11 Concrete Pedestal`'Dimensions:Width ft Length ft Thick <br /> in � Christy Box _ Stove Pipe <br /> PUMP CG Submersibleti Turbine (::I 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 /> 11INUNIi ill 24 1101 F N{l 1 H E.K1.01. IREO I.OR INSPECI IONS-I'I3r.:1SI{£'ALI,(209)95.i-7697 <br /> DEPARTMENT US O LY c� <br /> Application Accepted By Date Y' ' 9 � Area // 9 Employee ID# <br /> Grout Inspection By Date C i��Q '\_�"L�: l SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring JInspection By Date Constructed Well Depth ft <br /> COMMENTS /V GJell <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B C h Remitted Service Request# <br /> v3(o(0 <br /> y39/ <br /> �39Z 'f <br /> L•IID043-0604i072022 // �)/_D'2�2 Pn,e I oft Rcl :Pump Pc-mri <br />