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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 /> Joe ADDRESS ^ CITY/ZIP �1514q� _ <br /> CROSS STREET ` fl j` 'r ' 110 LJ').APNa yo Pq RCEL SIZE .� <br /> ? ��LAND USE PLICATION# <br /> OWNER NAMEf <br /> 1 PHONE ��C! �� N <br /> OWNER ADDRESS l �l� �J7� Y I (a✓. CITYISTATE/ZIP_ C��%��� Z/ <br /> CONTRACTORK J 01` �;�Tu,Ce r Va PHONE <br /> CONTRACTOR ADDRESS /V 1.1 } (�Y� 1 ,�C� CITY/STATEIZIP <br /> SUBCONTRACTOR ` <br /> PHONE <br /> SUBCONTRACTOR ADDRESS '�—' <br /> CITY/$TATE/ZIP <br /> LICENSE -57 C C-61 D D-09 D Other NUMBER D �•� EXPIRATION DATE W <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE C Domestic/Private `7 Irrigation/Agricultural C Industrial ­ Water Quality Monitoring Soil Sampling/Characterization <br /> i i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well D Replacement Well [i Well Alteration/Modification D Other / <br /> C Monitoring Well(s) #of wells Soil Boring(s) #or borings -1 Geotechnical #or borings `/ <br /> Out-Of-Service Well D Out-Of-Service Well Renewal 7 Cross-Connection Repair /t/qY , o <br /> C. New Pum 'l Pum Replacement is Pum Repair C Raise Well Casing6 <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary '-1 Air Rotary D Auger D Cable Tool f] Push Point 7 Other NFEn�I%RQ�/N <br /> a C <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom Gravel Pack/Gravel Size gyp I 7}y <br /> E Conductor Casing in diameter I Conductor Casing Depth It NIS <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched �D Steel r. Plastic L! Stainless Steel D Other <br /> Grout Seal Depth o ft C Neat Cement(94 lb ba gJ 10 gal water) Sand Cement sack-,,,/7 gal water <br /> Bentonite(20%solids) I1 Other <br /> Grout Placement Method 5 Pumped D Free Fall L Other Fi Retardant/Accelerator(name) <br /> PEDESTAL �Installecl By C Driller ❑ Pump Contractor D Other <br /> ncrete Pedestal DDimenslons:Width ft Lengtft Thick <br /> in ` risty Box Stove Pipe <br /> PUMP xl§ubmersibleL Turbine G Other HP Pump Sel ft Standing Water Level it <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <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 N'O'rICE REQUIRED FOR INSPECI•IONS-PLEASE CALL(209)9--,3-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L L— Date S /3 as Area Employee ID# rCyl►i( <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date -1 C)—L-`t ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS yKl t vnr Pow �i 3asa <br /> r <br /> PE SC Received Check#/ Amount Permit/Codes InfoB _ Cash Remitted Date SeNi e e nest# Invoice# Well ID# <br /> y386 <br /> 05-1 <br /> ElID043.06 10/252021 <br /> Page I of 2 <br /> l4'ell;Pump 1'ermn <br /> . l`�Z 81oZS- 75 <br />