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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2H D `( - L,1k8& l��c-C,ni i7 CITY/ZIP (a A c- y o­l m <br /> CROSS STREET ` I,.V l .�'i APN O 5 01,5 DD <br /> PARCEL SIZE �"' LAND USE APPLICATION# 0 <br /> 1� CD <br /> OWNER NAME ' � --�I ,� C�C�SC!1 r� PHONE -St <br /> OWNER ADDRESS Z' IIS ` LFI`S l- �1-y aV CITY/STATE/ZIP 2/1 L-1 S -_3 (_ <br /> CONTRACTOR _ �y1 e r PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 )(Other L'Jv4cNUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) I Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE �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 Wells) #of wells ❑ Soil Boring(S) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION PAY <br /> Drilling Method El Mud Rotary Air Rotary . Auger Cable Tool Push Point Other r^I MEN <br /> Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/Gravel Size C°pffl <br /> ) Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel ❑ Other <br /> b Au <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other SAN JOAQUIN COU TY <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) MENT <br /> tKIMeNT <br /> PEDESTAL Installed By Driller Pump Contractor Other ^••7 •.-• <br /> �CConcrete Pedestal Dimensions Width—�ft Length ft Thick s <br /> n Christy Box Stove Pipe <br /> PUMP ><Submersible Turbine Other HP Pump Set^ L`O 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: CPS <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 /> \II\1\11 \1 24 1101 It \D\ \\( I:\(11 R F III Ot Illi l)I()It A I IO\,�- I'I L\til.('AH f209)953--69- <br /> DEPARTMENT USE ONLY <br /> f f QG <br /> Application Accepted By �Jf� L ` Date Area J / / Employee ID# � <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ! "� �`���Date t Z WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS Nem ,je I po r d W POo'13 3Sa <br /> PE SC Received Check#/ Amount Permit/ <br /> CodesInfo B Cash Remitted Date Service Request <br /> # Invoice# Well ID# <br /> y3 •o � ) 1. #IS-a <br /> EHDO43-06 10125/2021 Pace I of 2 U-ell 1'u Pa nw <br />