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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 <br /> �� CALL(209 963-7697 FOR INSPECTIONS �1EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5�/ (;• r n CtTy/ZIP f 1 LC�14 c� N <br /> �/ m <br /> CROSS STREET APN 257-Z�0— "/ M 9 <br /> PARCEL SIZE v LAND USE APPLICATION# p <br /> In <br /> OWNER NAME Q A (�( .1 l�� a LI PHONE y <br /> OWNER ADDRESS 1 3 c 2"�� PHONE <br /> /J 7q f <br /> CONTRACTOR i �J PHONE 'L7te c ~ `� <br /> CONTRACTOR ADDRESS 7 Cr17Y/$TATEIZIP L I <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CIITY/STATE21P <br /> LICENSE ❑ C-57 C-61 ❑ D-09 ❑ Other NUMBER IaxpIRATION DATE io J <br /> DOMESTIC WELL SA LING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/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 eReplacement Well ❑Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) A of borings <br /> ❑ Geotechnical �T <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �G'c,1, I <br /> V'New Pum ❑ Pum Replacement ❑ Pum Repair_ 0 Raise Wefi Casin C Vie <br /> WELL CONSTRUC ION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other 5 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav, e10 In diameter <br /> ❑ Conductor Casing_ _in diameter / Conductor Casing Depth ftyEq N /R� O/�M CUIJNTY <br /> Well Casing Diameter_ in Thickness/GaugeIASTMSched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑434��aE ENT4L <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack ffll0 iter <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method D Pumped ❑ Free F ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller KPump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions-Width 3 ft Length 1.3 ft Thick <br /> in ❑ Ch ri Box ❑ Stove Pipe <br /> Pump Submersible❑ Turbine ❑ Other HP_�_ Pump Set ft Standing Water Level J��7 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 /> A•ilr:'liv§f <br /> 2-4 11011.11 ADVAOXE XOT?CE REQULR✓D FOR 5_NS==E r Pt3NS-_PLs'.iLn C.Ai'L(2,39)90�3-7c;97 <br /> DEPARTMENT. 0 E O LY � <br /> Application Accepted By Oate !/O Aroa Employee ID# <br /> Grout Inspection By Date ❑ 5PecIAL Welt Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info Cash emitted Date Service Re nest# <br /> Cj• <br /> EED043-06 1=512021 Page l oft Well/Pump PCMm t <br />