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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 P�E <br />JRMI <br />/T <br />J �^ UALL (LUU) U0J-/bU1 FOR INSPECTIONS t1CYI {K�CJ 7 YEARFROMDATE ISSUED <br />JOB ADDRESS 1 Za (i � C &) A wa,, 2 & t CITY/ZIP r � 1;q /(/ h <br />"I 13LI _qS � � � LAND USE APPLICATION # <br />CROSS STREET ) e APN � 0_q'57- <br />PARCEL SIZE � <br />OWNER NAME VJ /1 /e' �V'2 /b)�I <br />OWNERADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 i_ C-61 I I D-09 Other <br />NUMBER <br />( JPHONE !_ /� <br />CITY/STATE/ZIP IkC i7?y✓,1�� 95 <br />PHONE 2O// / F-/2— <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE )e Domestic/Private n Irrigation/Agricultural I Industrial I I Water Quality Monitoring I 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 'SENT <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair — RECEIVFn <br />b New vump Hump Ke lacement _ t-ump Ke air Kaise well uaSln — <br />WELL CONSTRUCTIONCD c 2022Drilling Method I Mud Rotary i Air Rotary I Auger Cable Tool i Push Point -1 Other U <br />Proposed Well Depth ft Excavation in diameter ! I Open Bottom 11 Gravel Pack/Gravel Size AQU►h4r <br />Conductor Casing in diameter / Conductor Casing Depth ft HEAI T DE ENTAL <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic - Stainless Steel nOther DEPARTMENT <br />Grout Seal Depth ft i Neat Cement (94 Ib bag/5-10 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 />n i Christy Box Stove Pipe <br />PUMP Submersible'..,, Turbine I Other HP �� Pump Set___a7DQ 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Z' DEPARTMENT USE ONLY <br />Application Accepted By—� C' � Date 07� <br />Grout Inspection By Date <br />Pump Inspection ByZ Date <br />Soil Boring Inspection By <br />/ V <br />COMMENTS f' In) 1, <br />Date <br />Area q 7 Employee ID# Frei o k <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />PE SC Received <br />Codes Info py <br />Check#/ Amount <br />a Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request <br />J�Q o� 1 <br />.D� �Is� <br />•I 2 X12 � <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />