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4 <br /> E11 RILE® <br /> - <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT �`V CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> �jFROOM]DATE ISSUED <br /> JOB ADDRESS 2� (k 1 t CrrY/ZIP sh l t ✓LI m <br /> CROSS STREET <br /> �1 APN" 1-13- 0- 1� <br /> PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> OWNER NAME I 1 1 PHONE I A01110— - in <br /> OWNER ADDRESS ` CITY/STATE/ZIP, [I]n <br /> CONTRACTOR MI ; Y , 1�`V PHONE �f�`� J l[� LV <br /> CONTRACTOR ADDRESS 1 t , � J ' CITYISTATE/ZIP 1 Y 1 O(A 11 J 1rV 61C ,/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 E C-61 D-09 Other NUMBER ` 022_ EXPIRATION DATE V t' )p 20 <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria(4391)Jt Dibromochloropropane(4392) Arsenic(4393) ipq c <br /> Dom INTENDED USE estic/Private IrrigationiAgricultural : Industrial Water Quality Monitoring - Soil Sampling/Characterization C /CVc <br /> Public Water System GD <br /> If different from Owner. Nate,System Name Contact Name or Pnone Number <br /> TYPE OF WORK ew Well Replacement Well ❑ Well AlterationlModification Other 2023 <br /> Monitoring Well(s) #of wells ❑ Soil Bonng(s) "of borngs Geotechnical #of Ibr� OAQUIN <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair NFA�Ty GNI� N UN7y <br /> _ New Pump Pump Replacement D Pump Repair Raise Well CasingDEPA TA <br /> WELL CONSTRUCTION NT <br /> Drilling Method Mud Rota Air Rotary Auger Cable Tool i Push Point Other <br /> Proposed Well Depth�_ft Excavation 71 in diameter D Open Bottom Gravel Pack/Gravel Sized 1p in diameter <br /> Conduce r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GaugerASTM Sched 1 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> fVentonite(20%solids) Other <br /> Grout Placement Method'Pumped L' Free Fall Other ❑ Retardant/Accelerator(name) <br /> iPEDESTAL Installed By 0 Driller Pump Contractor Other <br /> Concrete Pedestal GDimensions Width ft Length it Thick <br /> lin Christy Box C Stove Pipe <br /> PUMP Submersible Turbine 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 s-,stems. 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 I.NSI'ECTtOVS-PLEASE C�LI_(299)953-769 i <br /> DEPARTMENT U EA11-3 <br /> NLY /GG <br /> Application Accepted By - Date � Area ' 1 1 Employee ID# ' <br /> Grout Inspection By Date -La-Zf f I SPECIAL Well Permit <br /> Pump Inspection By Date I_! WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Ce �Vi i _e sC a tot?tl 64 j <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By, Cash Remitted Service Request <br /> s / V, <br /> far/ ss' FF <br /> 392 74, <br /> ----------- <br /> EltoawaaAiroaa Pap I urz `,I�� �j I(��j�) `11�1"V212M <br />