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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT GALL (lUU) Vt)J-/bU[ FOR INSPECTIONS t_APIKhb 1 YEAR FROM DATE ISSUED <br />l� �O r ��� iC 11 <br />JOB ADDRESS l� d .. � � .� � i� ` CrrYRIP <br />CROSS STREET�! / + APN A� O % ui �1O `i PARCEL SIZE 4;1 LAND USE APPLICATION # r <br />OWNER NAME / f�i (91 rg'ei /C/ c,71 L PHONE,2a 1— , -7 S`J ,-, <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS P U+ '_;� �/!7 7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 A C-61 - D-09 - Other <br />°e"w 7I�n 7 i S3 <br />CITY/STATE/ZIP � 1 % �t LJ !' 7l�/ <br />CITY/STATE/ZIP <br />NUMBER <br />PHONE <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE X 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 - Geotechnical "of borings <br />- Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair PA Va w <br />New Pump Pump Replacement - Pump Repair - Raise Well Casing 'VI t: <br />WELL CONSTRUCTION <br />Drilling Method - Mud Rotary - Air Rotary - Auger - Cable Tool - Push Point - Other 4 AD_ <br />Proposed Well Depth ft Excavation in diameter - Open Bottom - Gravel Pack/Gravel Size c er <br />Conductor Casing in diameter / Conductor Casing Depth It SAN JO <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched - Steel - Plastic - Stainless Steel (-tE AQU/N C <br />Grout Seat Depth It -Neat Cement (94 /b bag/5 10 gal water) -Sand CementTipr�14(ater <br />- Bentonite (20% solids) - Other FENT <br />Grout Placement Method - Pumped - Free Fall - Other - Retardant/ ccelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor - Other j1/ Z <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick Ap <br />in _ Christy Box - Stove Pipe <br />PUMP Submersible- Turbine - Other HP 2 Pump Set ft Standing Water Level It <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 />MININIU-NI 24 11OUR .ADVANCI? NOPICI' REQI-IRED FOR INSPECTIONS - PLEASE CALL (209) 9:3-7697 <br />Application Accepted By �` /_ L_ <br />DEPARTMENT USE ONLY <br />Date Area_v_-i Employee ID# <br />Grout Inspection By Date �,� El SPECIAL Well Permit <br />Pump Inspection By ✓I Date ��% (I Z6 ❑ WAIVER Received <br />FN <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS ,Ng_vJ GV:.1 J VoJ POD `iI3 3,i I <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted Date Service a uest # Invoice # Well ID# <br />3 <br />EHD043-0610r25/2021Page I of 2. <br />/L,L � / -2 3 Well /Pump Pcrmit <br />( l 11 i�723 1>1e,1� <br />