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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 i <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` L I Q / J rA <br /> JOB ADDRESS I o 9 o y G �O IC..r. �010.4 4 l�S�. CITY21P L.OP i•i CA 95Z y o rrnn <br /> �lt Q 6 5 �. <br /> CROSS STREET /7Wy 90 yn APN 06 3/9 0 i S PARCEL SIZE��LAND USE APPLICATION# g <br /> OWNER NAME <br /> Ffa�_n /�fP��t PHONE ,?QQ— F��3-�oa3 N <br /> C ui <br /> OWNER ADDRESS 50.M CITY/STATE/ZIP Sc? <br /> CONTRACTOR r7 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 /> DOMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE g Domestic/Private : IrrigationlAgricultural ❑ 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 Boring(s) #of borings 7 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method Li Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other PAYMENT <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel PackR=EFl/t�in diameter <br /> El Conductor Casing in diameter / Conductor Casing Depth ft ������TT <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless 6�eel O �Otf� r <br /> Grout Seal Depth ft . Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement J/11V 1 mW7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(nam NTY <br /> fAt <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other HEALTH UIEFARTMENT <br /> ;X Concrete Pedestal :Dimensions:Width_g_ft Length—J - ft Thick V in <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP X SubmersibleC Turbine ❑ Other HP Pump Set Z0'0 ft Standing Water Level <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 /> \II\1\IL\1 2!IIOI It Alf\':\�C I:♦011Ct:Rt:�)LlRlill FOR 1�51'E("I'IU�ti-I'Lr:.\�I'.('\I.L.I'-n91 9>3-(0)7 <br /> DEPARTMENT USE ONLY �� <br /> Application Accepted By Date L LO Area Y' Employee ID# <br /> Grout Inspection B Date D SPECIAL Well Permit <br /> Pump Inspection Bt jy1-4�_ Date �JU D WAIVER Received <br /> Soil Boring Inspection By Date ,�t' Constructed Well Depth ft <br /> COMMENTS�/�l/ /(�K� 37�� �\ '\ �►,^Z�7yA-)aim � <br /> ON— <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Ca h Remitted Date Service Request# Invoice# Well ID# <br /> osl / • I-a <br /> EHM3.06 04/07/2022 Page I of Uploaded into Ac c e i a well/Pump Perms <br />