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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABIL_E PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS U.' t t ` h/ �Stp Lc 't t CITYIZIP Jt0t r j'0' V1 l! <br />l \C� APN G `i� �L > > PARCEL SIZE I 'tet LAND USE APPLICATION # <br />CROSS STREET 5`rl ��` +� ` L � � ^ � <br />OWNER NAME <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />CONTRACTOR �e�l rtV�t SO� T���11LOr\ `OW��TN`s' PHONE 1"IO <br />CONTRACTOR ADDRESS fC �r 1Hj�t +r�\ t I CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS —mom <br />LICENSE 'F, C-57 L C-61 L D-09 L Other <br />°�) 16-1-'�n 0 \ <br />1�qo <br />PHONE <br />CITY/STATE/ZIP Ji}Mii <br />NUMBER 1;� l EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)r'- Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural C Industrial C 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 L' New Well L Replacement Well L Well Alteration/Modification U Other <br />[I Monitoring Well(s) # of wells C Soil Boring(s) # of borings Geotechnical # of borings <br />❑ Out -Of -Service Well E. Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pum C Pum Replacement ❑ Pum Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method L Mud Rotary L Air Rotary RS Auger L Cable Tool L Push Point L Other <br />Proposed Well Depth •2 G ft Excavation li in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br />L Conductor Casing in diameter / Conductor Casing Depth ft w <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched L Steel L Plastic L Stainless StP1.- <br />�3�T <br />Grout Seal Depth ft &Neat Cement (94 Ib bag/5-10 gal water) L Sand Cement8Ti ix/7 gal water <br />L Bentonite (20% solids) L Other <br />Grout Placement Method ❑ Pumped )� Free Fall ❑ Other C Retardant / Accelerator (name) <_;.;17 <br />PEDESTAL Installed By C Driller ❑ Pump Contractor L Other SAN JOAQUIN COUNTY <br />Concrete Pedestal LDimensions: Width ft Length ft Thick ENVIRONMENTAL <br />n _ Christy Box L Stove Pipe HEALTH DEPART <br />PUMP L SubmersibleL Turbine L 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT US ONLY <br />-- <br />Application Accepted By <br />Date <br />a <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By } <br />Date ' 1 <br />COMMENTS <br />Area employee ID# <br />[J SPECIAL Well Permit <br />L WAIVER Received <br />Constructed Well Depth <br />Tb <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cas <br />Amount Datp Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />37 <br />z ., ,- <br />EHD043-UG 04`0- 2022 <br />Page 1 O42 <br />Well r Pump Permit <br />