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l WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE�+P/n�IERMIT (� Il C�A�LL�(209 953-7697 FOR INSPECTIONS r`E�`AXPIR�,lES 'I YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS Yo2_(j Jt-�IJ�) C\i 1�'�W ,r CITY/ZIP Sll4\I�N �i� 15)LV <br /> CROSS STREET J`�� ti/� � j APN G,L�I-�W�/ JU PARCEL SIZE �� LAND USE APPLICATION 7# 7 O <br /> OWNER NAME 1'� G�l(/1` {�PHONE /��{j}-/ <br /> jOWNER ADDRESS P 0 _�(f ('��`(�T CITY/STATE/ZIP '4 (Vf1,� <br /> CONTRACTOR rry J u �^PHONE ����G11 <br /> CONTRACTOR ADDRESS I / CITY/STATE/ZIP 1 Y` h`}� <br /> SUBCONTRACTOR 0W PHONE <br /> SUBCONTRACTOR ADDRESS {}CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER V v 1 iw EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private -� IrrigationlAgricultural - Industrial C 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 •`_New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #otbonngs Geotechnical nofborings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodivlud Rota Air Rotary Auger Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth _ft Excavation �l, in diameter Open Bottom CI Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter ff in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel - Other <br /> Grout Seal Tepth JX ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> BentonitQ(20%solids) Other <br /> Grout Placement Method'It Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By :� Driller Pump Contractor _ Other <br /> Concrete Pedestal-Dimensions:Width It 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 an}'water ,vclIs or surface water within 200' radius of proposed well. <br /> SIININIL'M 24 liO R ADVANCE NOTICE REQURED FOR INSPECIIU\S-PLEASE CALL(219)953-7b97 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By U Date 'V-3-2®Z65— Area Employee ID# 411 <br /> Grout Inspection B / 1 / Date Z Q C=4=Ziff�b ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMMENTS ��� �eLGL• <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# != Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> �0 2 �t <br /> 4 1� •� <br /> ft�R Iq( y <br /> FHD443-1160,!()7/2022 CC I] I ���( � P. I< i I( 1 into gcce!a Well lPunlpPennrt <br />