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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-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS t r rb- i ton CITY/LP l to C L� mD <br /> CROSS STREET F.?�E'n J , 04 <br /> k '�— APN . �, 7 PARCEL SIZE . SAND USE APPLICATION# r <br /> OWNER NAME ` �//,� tt�l•�© ���'�i+e�-� w PHONE �1 <br /> OWNER ADDRESS 1 1/ y V)Ll I 1 CITY/STATE/ZIP���' / <br /> CONTRACTOR ��Ll U� t .141 �. ,r�JPH`O�NEr 4 - 0 (' / <br /> CONTRACTOR ADDRESS V [_7Ll I \(�'9 CITY/STATE/ZIP [�. YW'r I'1 L .C,1)Q-`'(t\ <br /> SUBCONTRACTOR Y 11 PHONE <br /> SUBCONTRACTOR ADDRESS CIITTY1//STATE/ZIP <br /> LICENSE C-57 n C-61 n D-09 n Other NUMBER `� I/ EXPIRATION DATE �J <br /> DOMEsnc WELL SAMPLING: 1,General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 'Domestir/Private ❑ Irrigation/Agricultural :1 Industrial n 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 J Replacement Well ❑ Well Alteration/Modification �j Other <br /> , Monitoring Well(s) #of wells Soil Boring(s) #of borings i; Geotechnical #of borings <br /> J Out-Of-Service Well Out-Of-Service Well Renewal ! Cross-Connection Repair <br /> New Pump -, Pump Replacement Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary :1 Air Rotary n Auger n Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth �� ft 6tcavation in diameter " Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Couctor Casing Depth ft <br /> Well Casing Diameter 1n Thickness/Gauge/ASTM Sch M-2-1 Steel Plastic C Stainless Steel Ci Other <br /> Grout Seal Depth I ft [: Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ';KBentonite(20%solids) ❑ Other <br /> Grout Placement Method umped 7 Free Fall n Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller n Pump Contractor Other <br /> n Concrete Pedestal-]Dimensions:Width ft Length ft Thick <br /> in :1 Christy Box ❑ Stove Pipe <br /> PUMP �J 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 /> MINI IA124 wc.►c>€,ADVANCE NOFICE,,111 QUIRED FOR tm fxl€ ��€1� ..lrs l gat ° �t�,f2W, 76 <br /> > � DEPARTMENT USE� Q2J� lea � �( C� EmploeelD# ���{ <br /> NLY <br /> Application Accepted By c Date // y <br /> Grout Inspection By .J Date 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received pw� <br /> Soil Boring Inspection By ate Constructed Well Depth ^! <br /> COMMENTS I( (5/ Cn <br /> AfAlft <br /> PE SC Received Chec Amount Date Permit/ Invoice e <br /> Codes Into B Cash Remitted Service Request# <br /> i 5-0 2Z coo u k <br /> T <br /> EHDO43-06 1025/2021 Page 1 of 2 well/Pum Permit <br />