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l WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALv 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 /> / b � <br /> JOB ADDRESS V OkCAAMJ�' CITY/ZIP C/1 Ck/2 Z m <br /> /� D <br /> CROSS STREET APN (J ZlO Z5PARCEL SIZE LAND USE APPLICATION# a <br /> OWNER NAME (+ J I� PHONE-3 17 7 E.S' o V 3 7 <br /> _Q7 <br /> OWNER ADDRESS �/ v, I 4 CITY/STATE/ZIP <br /> CONTRACTOR !V"/�}• ,�/J< /d 'S.� /�/a,�/ J/1 PHOONE33y Y.72-S— <br /> CONTRACTOR ADDRESS <br /> �_ � ►J ry L�� CITY/STATE/ZIP <br /> SUBCONTRACTOR '6'J 7m g/Z.a't • y PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ?�57 I_I C-61 ❑ D-09 ❑ Other NUMBER 3 7 73CPs EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑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 >lew Well ❑ Replacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,)JItMudtary Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth—.?,a a ft Excavation /Y in diameter Open Bottom $e Gravel Pack/Gravel Size in diameter <br /> ❑ Condu r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedZ OC) LJ Steel Mastic ❑ Stainless Steel Other <br /> Grout Seal Depth Zd b ft Neat Cement(94 lb bag/5-10 gal water) �6and Cement /C). sack �I�y <br /> 11r <br /> Bentonite 20%solids) Other N <br /> Grout Placement Method .dumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By k2riller Pump Contractor ❑ Other <br /> F1 Concrete Pedestal❑Dimensions:Width_5�- ft Length' ft Thick ma nq <br /> in ❑ Christy Box I Stove Pipe <br /> PUMP Submersible,_, Turbine I_i Other HP Pump Set ft Standing Wat L <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the folly Ht@R� <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> Dzl­EPARTMENT USE ONLY Application Accepted By / ^'/ Date S J u)ZZ Arelf,�e <br /> Employee ID# <br /> Grout Inspection By a( c Date I 'o ZZ ❑ SPECIAL Well Permit <br /> � b(2 <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS �� 5 V� �� _ C9.��� GQNN <br /> PE SC Received Check#/ Amount Par Permit/ Invoice# Well ID# <br /> Co s Info ash Remitted Servics Request# <br /> V_ 4- 2 <br /> _ Z wro <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />