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r . <br /> EMAILED <br /> .taco (F <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205 - (209)468-3420 <br /> NON-REFUNDABLE <br /> �PERMIT /� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,,"1 I t/I O �//1 L� CrTY/ZIP VNChC_MP gFjZ 1 <br /> �CROSS STREET "\w V "I APN 11� 100 19 PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME 1 aIj� N7 1 ' �Q— - _ <br /> I - • PHONE <br /> n <br /> o <br /> OWNER ADDRESS CITY/STATE/ZIP , V <br /> iCONTRACTOR AnANIIS IyIIIVq INr PHONE _71A' ) u2_ <br /> 47 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP CA 52�7 <br /> SUBCONTRACTOR k1{' PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 - C�1 D-09 :I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:kGeneral Mineral/Coliform Bacteria(4391 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural : Industrial __ Water Quality Monitoring ❑ Soil Sampling/Characterizab <br /> Public Water System AA%ra All <br /> If dlfferen!from Owner. Water System Name Contact Name or Phone Number 1' <br /> Pit <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification ❑ Other D <br /> / Monitoring Wells) #of wells Soil Boring(s) #of borings Geotechnical # s <br /> Out-Of-Service Well Out-Of-Service Well Renewal G Cross-Connection Repair SqN ?0� <br /> New Pump Pump Replacement PumpRepair ❑ Raise Well Casingj <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rota i Air Rotary Auger Cable Tool Push Point Other H HROAfMEN 11 <br /> Proposed Well Depth�ft Excavation I _ in diameter Open Bottom X Gravel Pack/Gravel Size_in rC T <br /> Conductor Casing in diameter I Cond t��QQ��Casing Depth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM SchedW Steel Plastic D Stainless Steel Other <br /> Grout Seal Depth �' /-ft Neat Cement(94lb bag/5-10gal water) Sand Cement sackmixl7 gal water <br /> �Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall _j Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Driller - Pump Contractor Other <br /> Concrete Pedestal_'Dimensions:Width ft Length ft Thick <br /> �in Christy Box Stove Pipe <br /> PUMP Submersible-- Turbine Other HP Pump Set ft Standing Water Level — ft I <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, eater bodies or courses, drainage pattern, roads, existing vclls, 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\INll N1 24 HUL k AD\.A\(1.\01 R I.RI_Q1 II(I.D FUR I\SPk( I lu\S.-Ill.LA.sL C:U.L(.0)943.761)' <br /> DEPARTMENT USE O LY <br /> Application Accepted By W Date 2 9� Area Employee IN 57-- <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth R <br /> COMMENTS .5 ®"S' f .�`� '•VAC y}tji S? k�� 1 <br /> _( ffz - <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WeI11D# <br /> Codes Into B ash Remitted Service Request# <br /> / Va 3 � <br /> C <br /> a s <br /> int <br /> EHDO43-0604/072022 aI-7 78-1 yIbstJ���'l��Iof1 WcII/PumpPcrma <br />