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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 - CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> /ISSUED <br /> JOB ADDRESS y CITY/ZIP�l,t l <br /> / D <br /> CROSS STREET A P N! �"9—C4 0- PARCEL SIZE LAND USE APPLICATION# o <br /> A /� l , �"/� tom) �/f �J m <br /> OWNER NAME ora k a r r � � k t,- PdHONE h� v—2 ` � qq N <br /> OWNER ADDRESS V A �C I CITY/STATE/ZIP S v`"1 CLA �� rt N <br /> CONTRACTOR tl /VUJ� 'D �_ CJI Dn N i � { J PHONE' <br /> CONTRACTOR ADDRESS �� / 4/� CITY/STATE/ZIP , ' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 _ D-09 Other NUMBER L U � EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural C Industrial I i Water Quality Monitoring Il Soil Sampling/Characterization <br /> I I1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well i i Well Alteration/Modification i_ Other <br /> I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method dlud a Air Rotary i Auger i I Cable Tool I I Push Point Other <br /> Proposed Well Depth ft Excavation _ ) :)== in diameter !i Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched SteelMastic Stainless Steel Other <br /> Grout Seal Depth "?sf}�� ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> entonite(2 o solids) i i Other <br /> Grout Placement ethod Wumped n Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal i;Dimensions:Width ft Length ft Thick <br /> in I; Christy Box i I Stove Pipe <br /> PUMP I I Submersible l I Turbine 1 i 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 /> \II\I\1I \I 23 1101 R 1D\ 1\('I:No I R 1: RL01 IRI:1) 1.()R I\SP1:( IlO\ti-111,1,VS].( U.1-(209)')>3-7697 <br /> !�ft; ARTMENT U ONLY <br /> Application Accepted By Date Area �. Employee ID# <br /> Grout Inspection By ���"�� Date /Z�—,�—Z oiL 11 SPECIAL Well Permit <br /> Pump Inspection By Date I.� WAIVER Receiv?4 <br /> Soil Boring Inspection B Date Constructed Well Depth �� ft <br /> COMMENTS <br /> P <br /> PE SC Receivedeck#/ Amount Permit/ <br /> Co Ifo B ash Remitted Date III Service Re uest# Inv .cWITI D# <br /> e' 1C,v o FN N� <br /> F <br /> ZZ <br /> EH13043-06 04/07/2022 Page I ort Well i Pump Permit <br />