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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIIT+ GALL (LUU) J53-tt)y/ FOR INSPECTIONS tAt'IKtJ l TEAR FROM UATE ISSUED <br />JOB ADDRESS <br />,15 <br />/ <br />J . H, oc R <br />/ <br />CITY/ZIP tat ����� <br />.0 <br />CROSS STREET <br />' f ! <br />W..V/rAC, <br />7r� <br />APIN 0� <br />PARCEL SIZE r��%��G—LAND USE APPLICATION # <br />ko•Z2 W 0043 V1 <br />��}J <br />%JP1n�noot I <br />SLLA'0131 <br />OWNER NAME <br />oCW�r <br />VNr7:CCC, *-44 <br />PHONES <br />OWNER ADDRESS <br />1/ <br />I <br />E, �/linc S(1 et <br />t� <br />CA <br />CITY/STATE/ZIP a' CA 1521 D <br />CONTRACTOR <br />t0_ r5 <br />_�j+W_ <br />eta m'0% <br />PHONE <br />CONTRACTOR ADDRESS 1133 n "L, -s 1 '-0,, t <br />SUBCONTRACTOR 1n101atk '- <br />SUBCONTRACTOR ADDRESS `)050 �C&LSlH'j (C�!•�G{ <br />LICENSE "/C-57 I-1 C-61 CI D-09 ❑ Other NUMBER <br />CITY/STATE/ZIP Garr CA X9 56 52 <br />PHONE 31(7 <br />CITY/STATE <br />`4/ <br />,ZIPJaC/bIr1G D� (A '"15pj <br />2Ct� t <br />�IOLEXPIRATION DATE j-{ /so <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 Z # of borings <br />❑ Out -Of -Service Well CI Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u New rump u rump Replacement ❑ rump Kepair ❑ Raise well casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger CI Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 2w ft Excavation . in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Oth _ <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement NTT <br />I Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑Pumped Free Fall N/ Other -'-(ye 11 mss- ° Ite ardant /Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other I'IHR 1 h 11177 <br />❑ Concrete Pedestal DDlmensions: Width ft Length ft Thick <br />in Christy Box I Stove Pipe SAN JOAQUIN COUNr <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Wa{N <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 />D E P A R T M E N T U S E O N L Y r <br />Application Accepted By Date Date 3 (, r7o� Area y 1 Employee ID# ! Tib 11 <br />Grout Inspection By Date 'Z Z�L ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />m <br />D <br />0 <br />m <br />m <br />Ca <br />CO) <br />PE <br />Codes <br />SC Received <br />Info 6 By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />Li37a;t <br />45 Z3 d_u <br />6 <br />ko•Z2 W 0043 V1 <br />EHD043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />