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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 'I YEAR FROM DATE ISSUED <br /> ` v I ---- -- - N <br /> JOB ADDRESS j 0 7p�� G 7-0 k— CC-1.4 Rdl. CITY/ZIP odii CA 95Z y o m <br /> ,` n <br /> CROSS STREET Pw Q p yn - _APN 06 3!9 0 19 PARCEL SIZE��LAND USE APPLICATION# a <br /> OWNER NAME f&;4 /dl/t�Pi4 PHONE ?oq- (60 3- &0 a 3 N <br /> OWNER ADDRESS .51key)to- CITY/STATE/ZIP 5ezW1.c <br /> CONTRACTOR he PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)" Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE g Domestic/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 WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Bodng(s) #of borings ❑ Geotechnical #of borings <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 Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other PAYMENT <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PackRE-C%E f'_/cr_in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft G�J <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Otr <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement J ( mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(nam NTY <br /> PEDESTAL Installed By n Driller ❑ Pump Contractor ❑ Other TMEN <br /> Y*Concrete Pedestal❑Dimensions:Width_eft Length JZ_ —ftThick J1 in <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> -�j PUMP X Submersible❑ Turbine ❑ Other HP_ Pump Set Z00 ft Standing Water Level 0 O 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 /> DEPARTMENT USE ONLY <br /> Application Accepted B_ �FIY Date � aL Zee k Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS1� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Ca h Remitted Service Request# <br /> os i( 5 f I.a. <br /> EM043-06 04/07/2022 Page 1 of 2 Uploaded into Acce f cl We11/Pump Permit <br />