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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 h CITY/ZIP `—t✓ J ! m <br /> CROSS STREET /�'�_Jy !iLi K APN �� ��61 PARCEL SIZE LAND USE APPLICATION# 0 <br /> A <br /> ai <br /> OWNER NAME 4 G�� r— PHONE <br /> c1/ r <br /> OWNER ADDRESS `>i CITY/STATE/ZIP <br /> CONTRACTOR 'ti 1 `:���` %r !� PHONE <br /> }Jr/ 7 C L <br /> CONTRACTOR ADDRESS , ! CITY/STATE/ZIP <br /> SUBCONTRACTOR ? i C 7 / r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,,<<C-57 11 C-61 [ID-09 I I Other NUMBER ! j „\ EXPIRATION DATE ) '� <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) Ibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 1.1 Irrigation/Agricultural 1-1 Industrial ❑ Water Quality Monitoring F1 Soil Sampling/Characterization <br /> Li Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK '_�New Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings i I Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �C��VED <br /> ew Pump n Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION 41 U6 , 2019 <br /> Drilling Method,�. ud Rotary I l Air Rotary I Auger ❑ Cable Tool J Push Point ❑ Other SAN_1^._ <br /> Proposed Well Depths ' ft Excavation L n diameter ❑ Open Bottom Gravel Pack/Gra�i /gp (igy�i�lreter <br /> I_I Conductor Casing in diameter / Conductor Casing Depth ft TH L)EFpART FM <br /> ENT Casing Diameter� in Thickness/Gauge/ASTM Sched ,, Steel Mastic Stainless Steel 1 Other NT <br /> Grout Seal Depth/',) i <br />