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I WELL/PUMP PERMIT <br />SAN UOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />CALL (1U9) Ub3-/tiy( FOR INSPECTIONS hAPIll 1 YEAR FROMM DATE ISSUED <br />CITY/ZIP / _ —_ �, 953'� <br />_IIAPN V6 - ��'t '",PARCEL SIZE �/� t=� LAND USE APPLICATION #G ✓� <br />1 , / /I/JXJ� ✓,S/1'� PHONE � �,a(aLq533-4 <br />✓ s2co <br />OWNERADORESS �/—o[i�u;f�i /yv�nV4 CITY/STATE/ZIP �cl�� C— g533 T• <br />CONTRACTOR I� � � (_fir l( �^Gt PHONE 2-� �MVq - � 7 Z7 <br />CONTRACTOR ADDRESS 1133 31�� rL;L,- CITY/STATE/ZIP <br />SUBCONTRACTOR ^ x� — NI�f' Q S�+ c�����7� !PHONE <br />SUBCONTRACT/OR ADDRESS i(/J� 4ilrt�5�lic / /Ju✓/OVc c' _ CITY/STATE/ZIP <br />^ <br />w�✓��ct+1¢•O (�Fi %56�� <br />LICENSE `�V C-57 C -fl F1 D-09 0 Other NUMBER ,797ci,"JEXPIRATION DATE q/�0_Zeiq <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ; 1 Irrigation/Agricultural I- Industrial ❑: Water Quality Monitoring L 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 I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings—V/Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ...; Cross -Connection Repair <br />_ ❑ New Pump I= Pump Replacement ❑ Pump Repair CI Raise Well Casing <br />WELL CONSTRUCTION / <br />Drilling Method ❑ Mud Rotary Air Rotary VI Auger ❑ Cable Tool Push Point C Other <br />Proposed Well Depth , . r D ft Excavation �t I� ,i, " [ <br />p p � in diameter -Open Bottom C Gravel Pack/Gravel Size i" zTi er <br />Conductor Casing in diameter / Conductor Casing Depth ft IES `DIED <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ;- Steel G Plastic C Stainless Steel ❑ Ot e <br />Grout Seal Depth a1 ft �7 Neat Cement (94 Ib bag15 10 gal water) ❑Sand Cement a mr�Cl g typer <br />Bentonite (20% solids) Other �'(= l JLL <br />Grout Placement Method Pumped ❑ Free Fall V( Other _, T&OU Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 1 Pump Contractor 0 Other_ ENVIRONMEN H <br />L I <br />Concrete Pedestal CDimensions: Width ft Length ft Thick - - " T <br />n Christy Box G Stove Pipe <br />PUMP 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 />N11 \ I NIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PILL.\SE CALL (209) 953-7697 <br />DEPARTMENT USEONLY � <br />Application Accepted By 6` Date �� 0 Arel tr Employee ID# <br />Grout Inspection B _ _ Date ❑ SPECIAL Well Permit <br />Pump Inspection By _ Date ❑ WAIVER Received <br />Soil Boring Inspection By Date ,� FAL ,Cr"Lt>-<�7&gnstructed Well Depth <br />COMMENTS <br />ft <br />T <br />m <br />D <br />O <br />0 <br />A <br />M <br />Cn <br />PE Sc Received Check#/ Amount <br />Codes Info B Cash Remitted Dat <br />Permit/ <br />Service Request # Invoice # Well ID# <br />if-'> 0 7 9 <br />EHDO43-06 04/072022 Page 1 of 2 Well / Pump Permit <br />