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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 />IVVI I-KEFUNDABLE VERMIT( <br />t ALL (LUy) y53-fOUf FOR INSPECTIONS <br />7 TTEAR FROM UATE ISSUED <br />JOB ADDRESS C?�.� <br />i1 <br />J . 1 ICM <br />/ <br />/�4nfr <br />CITY/ZIP rCwt <br />�tAll'IKC, <br />q 15aL—I/Z <br />�. <br />�D9.1".i <br />031 a `i'D 0 <br />M t <br />w <br />CROSS STREET ly_ <br />ree <br />APN <br />PARCEL SIZE t � <br />LAND USE APPLICATION # <br />//U// <br />J )�y�t <br />oyf.%,. 9c.�.obi <br />a <br />A <br />OWNER NAME .6r't <br />[_ J;S/ <br />n`GI <br />PHONE /� <br />OWNER ADDRESS 130.5 <br />E. Ib".. <br />sf--f <br />CITY/STATE/ZIP <br />ZA CA �/7 ✓,2-fL/ <br />CONTRACTOR Awl <br />E"., <br />GL, ' l Z t1\01 <br />� 111 .�J� <br />PHONE <br />1^ - 633 <br />-- x5 <br />2 <br />CONTRACTOR ADDRESS <br />575 tit <br />&,Igvj <br />n' <br />&/;7O ,2!1' Z12 <br />CITYISTATE/ZIP <br />S- <br />[[�� <br />fE,u..x .CA Qi -15y5 <br />'-23 <br />SUBCONTRACTOR y�W�p..C/+jG�— <br />KV0 <br />Asso i-Ij <br />PHONE 416- 317.2 <br />- N 3q <br />SUBCONTRACT/OR ADDRESS �/5C7 �,GQu <br />j+b.( e& <br />( �/J� <br />I'6 �rSX <br />CCIITTYISTATE/ZIP � <br />� ..�J'G.�V1G,�jy/�. <br />1 <br />LICENSE N C-57 <br />C-61 ❑ D-09 <br />❑ Other <br />NUMBER <br />O'1 rZ y51 <br />/� <br />EXPIRATION DATE 6 <br />J�/4S6�=t <br />3C7/ 20,23 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 7 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 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />❑ New <br />WELL CONSTRUCTION <br />VGeotechnical 1# of borings <br />❑ Cross -Connection Repair <br />L raise wen <br />Drilling Method ❑ Mud Rotary Air Rotary ❑ Auger ❑ Cable Tool O/Push Point ❑ Other <br />Proposed Well Depth 1:;Qft Excavation 1.15 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ ( <br />Grout Seal Depth 50 ft ❑ Neat Cement (94 /b bag/5-10 gal wafer) ❑ Sand Cement <br />i i Bentonite (20% solids) ❑ Oth, <br />Grout Placement Method ❑ Pumped 6(Free Fall <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor <br />I I Concrete Pedestal ❑Dimensions: Width <br />in ❑ Christy Box ❑ Stove Pipe <br />❑ Other_ <br />ft Length <br />/ Accelerator <br />ft Thick <br />in diameter) <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing W eLeve <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 />MINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By /�Date -311r1R_? <br />Grout Inspection By A . Date ZZ <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Lo� Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />N <br />mm <br />D <br />0 <br />0 <br />m <br />ti <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />Ll 3'7a ) 5 O <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Permit <br />