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• � �_1_a s � <br /> A?SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT L��PUMp PE <br /> NON-REFUNDABLE PERMIT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> CAL 209)953-7697 FOR INSPECTIONS <br /> JOB ADDRESS 1�n'tV EXPIRES 'I YEAR FROM DATE ISS <br /> *1'o*1'o� <br /> c V cm/ZIP <br /> IM�- SU <br /> N I y <br /> CROSS STREET �1 ' R �J 11�I APN.J �J- I�Q m <br /> ZZO PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAMErJ�/� <br /> lr �j ho. - Maar P. q. �S P E CI V •.�� - � Q('' N <br /> OWNERADDRESS J I✓ (j�'P �/� 61 <br /> I 1 CITY/STATE/ZIP N �� <br /> CONTRACTOR y II I 1 1 1 /� PHONE 2101 fiL�ZI it.I <br /> CONTRACTOR ADDRESS 1� 1 CITYISTATE/ZIP��I tQ(A( ) 0(k 41/ Cl I <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE \�C-57 C C-61 _ D-09 11 Other NUMBER �� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> j INTENDED USE omestic/Private l- Irrigation/Agricultural Industrial - Water Quality Monitoring -1 Soil Sampling/Characterization <br /> Public Water System <br /> j If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well , G Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of bo"rys Geotechnical "f borings <br /> Out-Of-Service Well ❑ Out-0f-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement - Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rata Air Rotary Auger 0 Cable Tool Push Point Other <br /> Proposed Well Depthft Excavation 11 it in diameter Open Bottom `Gravel Pack/Gravel Size in diameter <br /> Conduct�jr Casing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameter 4 in Thickness/Gauge/ASTM Sched Steel Plastic _ Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal water) :(Sand Cement 10) sack mix/7 gal water <br /> BentornteJ20%solids) Other ft�� <br /> Grout Placement Method Pumped Free Fall - Other Retardant/Accelerator(name) <br /> � EESTALEInstalled By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick <br /> ChristyBox 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 propert} lines. For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> >IININIL-%I 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Alv& Date 7'3 20Af' Area Employee ID# 37— <br /> Grout Inspection By Date -/ X SPECIAL Well Permit <br /> Pump Inspection By / Date WAIVER Received <br /> Soil Boring Inspection y Date Constructed Well/Depth ft <br /> COMMENTS -C C iY It S V/ ri t ,H �✓d/�rr 7�dl�L- <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash C emitted Service Request# <br /> V3K /90 At I t/` •d 1 25 P 2 Q>Z I ) <br /> 3 vo �- <br /> 62, <br /> i <br /> DIDO::_rtr,04'117 2022 Pag I oft U p o a e n LCCI <br />