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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 />NUN-KEFUNDABLE VERMIT GALL 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�- C <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET N APIN o63 a PARCEL SIZE q► SG1 LAND USE <br />APPL�ICAQTION/# <br />OWNER NAME / a PHONECXr [ " `5 - O / <br />OWNER ADDRESS /0 /65• E6J tJ{J/6W Pd CITY/STATE/ZIP/-0/y CA ` o ;x/l / <br />CONTRACTOR Y PHONE..Qc(`• � `��^�/ , <br />CONTRACTOR ADDRESS CITYISTATE/ZIP �J C%�'�! 167 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />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 />❑ 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 # of borings <br />❑ Out -Of -Service Vyell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump X Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <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 lb beo-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 ` Submersible❑ Turbine ❑ Other HP Pump Set / `Y ) 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 />11IA7MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By -e�--L L Date o7 a al a Area `I 1 �/ Employee ID# FfGv1 F C <br />Grout Inspection By A Date ❑ SPECIAL WellLo— <br />Pump Inspection By Date '7- 4 [J WAIVER Rec MFNr <br />Soil Boring Inspection By Date Constructed Well Depth `��� ft <br />COMMENTS _ <br />PE <br />Codes <br />SC Received hec <br />Info By Cash <br />Amount Date Permit/ <br />Remitted Service Re uest# <br />In Rp M CO ID# <br />3 &T <br />oTO 0477< <br />47 77 2-1 0 2 2 <br />EHD043-06 10/25/2021 Page I of 2 Wel I / Pump Permit <br />