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1 -----p - 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 /> p j <br /> JOB ADDRESS • Ir A CITY/ZIP ` /- m <br /> t77 �Q✓/ APN � / �" ��/O PARCEL SIZE LAND USE APPLICATION# <br /> CROSS STREET AA 4 �j m <br /> cn <br /> OWNER NAME 12&ar , v `l% V PHONE (`a 7 N <br /> OWNER ADDRESS �j..skyyz/� n CITY/STATE/ZIP <br /> CONTRACTOR V /mss PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP VV <br /> 312.0 <br /> SUBCONTRACTOR =S PHONE '1. � <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER�/7 EXPIRATION DATE — � <br /> DOMESTIC WELL SAMPLING:❑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 WORKA4°New Well ❑ Replacement 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 /> 0<ew Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mudto ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth��ft Excavation /'2_� in diameter ❑ Open Bottom I>dravel Pack/Gravel Size in diameter <br /> ❑ Conductor-Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal DepthZ2j.�- _ft ❑ Neat Cement(94 Ib bag/5-10 gal water) and Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-4CPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By -N=riller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ 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 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 /> DEPARTMENTUSEONLY 9 <br /> Application Accepted By Date / �S/ZZ Area q 1 Emp <br /> Grout Inspection By �f/ `} Date ��L ❑ SPECIAL W@II P@rm <br /> Pump Inspection By Date ❑ WAIVER RecelvW1 J C 20;? ft <br /> Soil Boring Inspection By Date Constructed Well Dep rS <br /> COMMENTS EAf <br /> D ( <br /> PE SC Received Chec Amount Date Permit) Invoice# Well ID# <br /> t <br /> Codes Info By Caph Remitted Service Reque <br /> 3 � 60 zo S 157- <br /> '13 <br /> 2'13 C1/ / SS <br /> 9`392 <br /> ERID043-06 04/07/2022 6 <br /> Page I of 2 Well/pump Permit <br />