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1 • Y, awl` <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 F05 I SPECTIONS EXPIRES 1 YEAR FROM <br /> (DATE ISSUED <br /> JOB ADDRESS O l CITY/ZIP � ��!/ C m <br /> D <br /> o <br /> CROSS STREET I APN PARCEL SIZE LAND USE APPLICATION# <br /> A <br /> m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP (/�f�J <br /> CONTRACTOR I PHHO'NE O 3y'' JG�` `:% <br /> CONTRACTOR ADDRESS /✓V /r'3 CITY/STATE/ZIP k; typ�IL��,(/G/,(/ <br /> SUBCONTRACTOR e_ �'S � PHONE 3 42-/• 2 PLO <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �-57 ElC-61 ElD-09 El Other NUMBER— <br /> ?- /v VZIr 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 /> 11 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well ❑ Replacement 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 /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ;Xud 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�6_ in Thickness/Gauge/ASTM Sched T-M ❑ Steel J;Mlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth :2AD ft ❑ Neat Cement(94 lb bag/5-10 gal water) "and Cement /c?, 3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other P"M els�r <br /> Grout Placement Method VPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By >6riller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pl5destal DDimensions:Width ft Length ft Thick B 2_5 nAnn in ❑ Christy Box El Stove <br /> Stove Pipe J [uL <br /> PUMP Submersible❑ Turbine ElOther HP Pump Set ft Standing Wate IN COIN <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the follq obi <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 NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEP RTMENT USE N L Y <br /> Application Accepted By J Date �f/Y Area '.9 Employee ID# <br /> Grout Inspection By I . Date Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date I 1 WAIVER Received <br /> Soil Boring Inspection By �" �Date Constructed Well Depth ft <br /> COMMENTS 1_/eLI 10Cc -f— d 'h eQ [ fJ _M✓1.Sr 021, <br /> PE SC Received Check#/ Amount Permit/ <br /> Co es In o B Cash emitted Date Service Request# Invoice# Well ID# <br /> �_S7 zti 2 (4 11 <br /> U 1 <br /> o <br /> EHD043-06 10/25/2021 Pagel of2 Well/Pump Permit <br />