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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 O F CITY/ZIP m <br /> CROSS STREET • 1 � ,� �,�J( � APN 11 1 f C—h�C� PARCEL SIZE U LAND USE APPLICATION# <br /> OWNER NAME r II PHONE <br /> OWNER ADDRESS —1 , fC J <br /> 1'L-1— / t 11 ! CITY/STATE/ZIP � + j� <br /> CONTRACTOR t 'V f��/11I�/D1 ('�`�`�t�~ _ PHONE �`�, , �W 01 C)/ �,-i <br /> CONTRACTOR ADDRESS U rJ`►/" , `—1 � CITY/STATE/ZIP �'1�Y�` <br /> SUBCONTRACTOR �' \� (/\ PHONE <br /> SUBCONTRACTOR ADDRESS (CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria(4391)xDibromochloropropane (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 >e New Well ❑ Replacement Well LI Well Alteration/Modification ❑ Other <br /> I-1 Monitoring Well(s) #of wells CI Soil Boring(s) #of borings Geotechnical #of borings <br /> _1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method%e Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth S2 C- ft Excavation _ in diameter ❑ Open Bottom X' Gravel Pack/Gravel Size in diameter <br /> Ll Condu or 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 O-A-,n ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> �IS Bentonite(20%solids) 11 Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Li Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box !1 Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ 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 /> 11i\I%if `1 24 1101, I ADI XN( 1:\0I R F R]-'Qt Itti;1}1()id l�+I`i,( 11()Ids-I'Ll'kti1:( Al 1,(209)953-'f,t)` <br /> 12� <br /> J DEPARTMENT US O LY / <br /> Application Accepted By Date /2" J 9 7� Area /7 y PAYS <br /> Grout Inspection By Date ( z. ❑ SPECIAL WA <br /> Pump Inspection By Date ❑ WAIVER R iv@ ;A <br /> Soil Boring Ins ection By Date Constructed Well Depth 19 2,2 ft <br /> COMMENTS ID J'615V7 G <br /> e , i,��' M SUN z <br /> PE SC Received heck Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# D# <br /> Y3&6 IS-0 <br /> 5�39 76 <br /> EHD043-06 04/07/2022 Page I of 2 <br /> Well;Pump Permit <br />