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1 , WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PERMIT GALL (2U9) 95J-Tb9l FOR INSPECTIONS hAPIKhb 9 YEAR FROM UAT,E ISSUED <br />JOB ADDRESS �JQy avi1UV) f t/" CITY/ZIP V'�(.kokx(L I ql�;76 <br />CROSS STREET IJU V 't�'Ia 4/ C APN `� ~l 0 -� I PARCEL SIZES P ' LAND USE APPLICATION # <br />i� I1 <br />OWNER NAME Mow) 'i, Jt l/`W`�/ (j PHONE <br />OWNER ADDRESS ' l w Ll)� ��� C nn CITYISTATEIZIP iywwal,11`1 ✓ ✓� <br />CONTRACTOR V 11 v 1 ( <br />- PHONE ��ocl) 14GA 100 <br />CONTRACTOR ADDRESS, <br />! 1� �7h ?�iGtl 1�\ t ( CITY/STATE/ZIP �l�l + I� + M <br />SUBCONTRACTOR W Uk ((� — kA\n ` t `,� A )Yo �(( ,,J ` PHONE l t llJ� I _ 4 z 1!� <br />SUBCONTRACTOR ADDRESS -3) � 1 V Uv14I�SC Y t� ( i i -� CIT <br />Y/S <br />T <br />A <br />T <br />E <br />/ZIP al -o F" l;a C C •J'_th+- /(A Jq (;M l <br />LICENSE 6/ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER Fl/ l V ` EXPIRATION DATE "I 1 2 IZ0 <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 />0 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 />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings geotechnical k 2 # of borings <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair —� <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary [J Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth_c - ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Sized in <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft �q4) <br />Well Casing Diameter _ in Thickness! auge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑ Oth <br />Grout Seal Depth S - '2>0 ft YNeat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sa <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped T;Tree Fall ❑ Other ( t Wt 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 ❑ 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 />NUNINIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By ��✓ <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date 1#4 1.7,w 1.77 <br />Date l <br />Date <br />Date <br />Area 31f401 _64 Employee ID#�� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />D <br />0 <br />m <br />N <br />PE <br />Codes <br />SC Received Chec <br />Info By cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted ervjcp guest # <br />37a <br />15-0 5 <br />aso z <br />F=1 <br />I I <br />EBD043-06 10252021 Page I of 2 Well / Pump Permit <br />