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EMAILED <br /> 1 WELL/PUMP PERMIT 1 ` ��\\/\ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS IR . V R0 11�f -f 1 (`-0- /� CITY/ZIP r �� 14i� 3� m <br /> LA <br /> CROSS STREET UV, �� 1 ! APN )SIJ - ING- 141 i PARCEL SIZE i 14 LAND USE APPLICATION# p <br /> OWNER NAME K I I'-t o ! L) PHONE 4 A &L' l `-a._)1]r N <br /> OWNER ADDRESS `` G: I/*l/1 CITY/STATE/ZIP <br /> CONTRACTOR ['t 1, I-F' Vt I'Vl II ( PHONE�r� �°X—tJk/C,4 <br /> CONTRACTOR ADDRESS G L CITY/STATE/ZIP� <br /> SUBCONTRACTOR 1t f� PHONE <br /> SUBCONTRACTOR ADDRESS CITYIST1sA-T'TE/ZIP LICENSE C-57 :.. C-61 7 D-09 LI Other NUMBER �� ` _3 EXPIRATION DATE �l <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )-(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 u Well Alteration/Modification 11 Other <br /> L]Monitoring Well(s) #of wells !l Soil Boring(s) #of borings Geotechnical bori 1' <br /> ❑ Out-Of-Service Well I Out-Of-Service Well Renewal Ll Cross-Connection Repair <br /> _' New Pump - Pump Replacement -_1 Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION ,nn <br /> Drilling Method ><Mud Rotary - Air Rotary _ Auger - Cable Tool _ Push Point Other SA411 JOA <br /> cf�6 <br /> Proposed Well Depth ZIP,D ft Excavation 13�_ in diameter f- Open Bottom XGravel Pack/Gray 07 er <br /> Conduct r Casing in diameter / Conductor Casing Depth ftdT,1 <br /> Well Casing Diameter kQ in Thickness/Gauge/ASTM Sched �+�- i: Steel A Plastic Stainless Steel Other rAlI Aj— <br /> Grout Seal Depth $ I lj p 0 Neat Cement(94 Ib bacy5-10 gal water) a Sand Cement sack mix17 gahwater <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped U Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contra Other <br /> Concrete Pedestal Dimensions:Width ft Length ") ft Thick <br /> in Christy Box Stove Pipe <br /> PUMP )(Submersible_1 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 any water wells or surface water within 200' radius of proposed well. <br /> Iii'N!1Ii11-'4t14}lt AD1 ;,( i.`,()Iik.LfLL'k. @IRI'i'lIORI\SVE(.I10N.'s-14,1_kS:('ALL(Zfl9}+)i;-7��? <br /> D PA TMENT USE ONLY, <br /> Application Accepted By Dale Area Employee ID# <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By Date l_ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENT <br /> PE SC Received Check#] Amount Permit/ <br /> Codes Lnfo B Cash Remitteo Date Service Request# Invoice# Well ID# <br /> 2 <br /> t:H1x113.06()4/07/2022 2 Page l of'_ N'cll/Pump Permit <br /> U <br /> C� <br /> pi®a d e d iz�.esz�l Ipto Accela <br />