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1 ' 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 EXPIIRREESS'r 1 YEAR <br /> FROM DATE ISSUED <br /> .108 ADDRESS4,Z e ^ CITY/ZIP �/�/F.l j� /�� m <br /> � /\ 1Q( D <br /> CROSS STREET rl•Ar_ A0 APN 33?Dy) PARCEL SIZE 17'°7C" LAND USE APPLICATION# / a <br /> OWNER NAME R1/5S eL- PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR r PHONE <br /> CONTRACTOR ADDRESS E CITY/STATE/ZIP ON LIT <br /> SUBCONTRACTOR iG// c u1eDr <br /> l I✓1 PHONE <br /> SUBCONTRACTOR ADDRESS CITY`/STATE/ZIP <br /> LICENSE C-57 C-61 ❑ D-09 ❑ Other NUMBER F EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(439 1)0 Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE V 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 Apeplacement 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 <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation �2 in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter d in Thickness/Gauge/ASTM Sched 44 ZCrO❑ Steel�lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /f_ft eat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method tfPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xpump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimensions:Width ; ft Length_7 ft Thick <br /> n ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level 'fit <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 /> MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> I 7 <br /> E� <br /> Application Accepted By Date '7�/ � Area � / Employee ID# <br /> Grout Inspection By11 t �� Date—' 1L� 0 SPECIAL Well Permit <br /> U <br /> Pump Inspection By � �' (Ali Date Z Z n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Ex,.slw -iellkwe r ��-cl rmif an 1I o7 A-117. /7'7o-rmejnS cilleCland <br /> S fq4o thelf W41 M eve sub n r si n4 beA "A 9/2 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice#RE E I V@[D# <br /> Codes Info B Cash Remitted i I Service EAWRW <br /> 9330 os) f. 11,210 i Is <br /> 370 19 ID r, toq 310 (AP 3W4 SER 2 0 2022 <br /> 939 /� r )�$' SAN JO QUIN COUNTY <br /> tNVIH ENTAL <br /> EHD043-06 04/072022 Page I of 2 Well/Pump Permit <br />