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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96205 - (209) 468-3420 <br />.i.r e..une% oe4_7a67 vne lmoact Anus FXPIRFS 1 YEAR FROM DATE ISSUED <br />..........- --- - --- - -- <br />C <br />J n �. <br />¢� J/' t le <br />JOB ADDRESS t ��!! �S 7OO S Ohio leel CITYIZIP��/,� ` r 7+ <br />e <br />L.� <br />CROSS STREET S7O 0 1 PARCEL SIZE aE_LAND USE # <br />i <br />LAPIN /� <br />spA/tPPLIICCATI(ONN <br />OWNER NAME ✓ C/� 1 ��1 �-L Ci'(G f / PHONE ' � L ` / D� r f <br />f <br />(OWNER ADDRESS / / CITY/STATE/ZIP <br />"n 5J1i����1tD 5ertll �� PHONE `d `®✓ t -3,Y5-'- <br />❑ WAIVER Received <br />CONTRACTOR <br />CBNTRACTORADDRESS &,5 -Cl l/-.i't-i�1 CITY/-S:TATEIZIP 4KJ'4& <br />Constructed Well Depth ft <br />LJ vjtxle, volirccl <br />SUBCONTRACTOR PHONE <br />COMMENTS Well / r <br />SUBCONTRACTOR ADDRESS ­11CiT��YISTATEIZIP <br />( <br />LICENSE ❑ C-57 61 ❑ D-09 ❑ Other NUMBER v .J EXPIRATION DATE 7` 3r�- 77 - <br />had 110fbeCY1 SPI -a C- <br />DOMESTIC WELL SAMP G: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />DOMESTIC <br />I„WS�,ok7Sf:LJttt, 1JNQQ <br />INTENDED USE omestic/Private ❑ Irrigation/Agricuftural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If difrprWrom Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK lees. Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # <br />❑ fdut-Of-Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair 44V `` <br />,( New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well Casing/ IQ <br />WELL CONSTRUCTION N Jpq <br />ENS/ QV/N <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 D w <br />RTM <br />ElConductgr Casing in diameter / Conductor Casing Depth ft �o <br />Well Casing Diameters _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant 1 Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width 1_ ft Length ft Thick ljo <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water LevelP 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 />UNID101 24 HOUR ADVANCE NOTICE REQUIRED FOR PiSPECTIONS - PLEASE CALL (209) 953-7697 <br />Application Accepted By �� <br />DEPARTMENT USE ONLY <br />Date S % <br />Area_'_ Employee ID#! f' v <br />Grout Inspection By <br />Date <br />❑ SPECIAL Weil Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth ft <br />LJ vjtxle, volirccl <br />COMMENTS Well / r <br />( <br />I rooft <br />had 110fbeCY1 SPI -a C- <br />�irvte kyf-ll <br />I„WS�,ok7Sf:LJttt, 1JNQQ <br />� <br />ffm Fm W, 'ZIRA <br />PIID043-06 10/25/2021 Page 1 of 2 Wcll /Pump Pmnit <br />