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Q <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN.-KEFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS v/ 1-{ H U -rI (I_YY) CITY/ZIP <br />CROSS STREET R bl%aa& G "f APN 099110, ur PARCEL SIZE LAND USE APPLICATION # C% <br />OWNER NAME K, eyi n v a� I Y 1a n PHONE O�6q-, JTI"[nLl— / m5 <br />OWNER ADDRESS _*40o U A4P. CITY/STATE/ZIP Sh k�10 -- <br />C g�a�a <br />CONTRACTOR VOOYt1/ IV, Srr..''AJQ,7ky �tb%M1 1h PHONNE_O?o�]-�?3�—Sal D <br />CONTRACTOR ADDRESS ala 0 ✓�/1 I LO)c Y1 Dad CITY/STATE/ZIP hck yr) Cr1 %`—jd./ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE $ C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER W I EXPIRATION DATE 1.311 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE X 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 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ;(Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <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 A Submersible❑ Turbine ❑ Other HP _Ly1t__ 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 />111\1 vI[ v1 24 HO[ R ,?D\'_\\CE NO"11( E RF.Q[iRED Hfl, I SfECTIO\S- PI_LASf i aLL (209) 9v--6()" <br />j ) DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date t v <br />Soil Boring Inspection By Date ' <br />COMMENTS n Uvt r [!."e� f ZZs rCAr; l�1 we 4iC BJP 11 -71`S I & i d <br />Area L Employee ID# 16'1 i k <br />❑ SPECIAL Well Permit <br />❑ WAIVER <br />Constructed Well <br />L) I I i f Zk� <br />ft <br />G <br />PE SC Received 64iZOP Amount Dat <br />Codes Info B Cash Remitted <br />Permit/ <br />Servicest # <br />I <br />vLJ <br />0 eIIID# <br />`>^ <br />H 3 $1 6570 L <br />'_M--;!5n <br />H /Ro <br />�oU <br />Fp <br />I V qt <br />T <br />EHD043-06 10/252021 Page I of 2 Well / Pump Pennit <br />