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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 <br /> NON-REFUNDABLE P5FN T CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS - CITY/ZIP J /pr�t(J/r m <br /> CROSS STREET (1)D// /r��`9 APIN CL 5_ ✓ 9 0^O✓PARCEL SIZE _LAND USE APPLICATION#_ oA <br /> OWNER NAME <br /> /— �! PHONE / (�y �l r v <br /> OWNER ADDRESS ,� /� /�f / CITY/STATE/ZIP <br /> CONTRACTOR �"0 rLL\(���✓P�` ��PH Z <br /> JONE J' �� <br /> CONTRACTOR ADDRESS O 7 LC <br /> CITY/STATE/ZIP / ')(i3O logs/of <br /> SUBCONTRACTOR PHONE 2v;7. <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE .4!r"r,-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER f ' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391))CDibromochloropropane (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 KNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ffllew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rot x ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth SN ft Excavation Z in diameter ❑ Open Bottom Gravel Pack/Gravel Siz in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad 2-00 ❑ Steel AITPlastic ❑ Stainl ss Steel ❑ Other <br /> Grout Seal Depth Zr:� ft ❑ Neat Cement(94/b bag/5-10 gal water) �cSand Cement /d'3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method>Oumped ❑ Free Fall ❑ 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 ater 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ,,,; E P A R T M ENT U S N L Y <br /> Application Accepted By Date ' / I — ( Area Employee ID# Sr <br /> — <br /> Application Inspection By Date , — ❑ SPECIAL Well P01 <br /> Pump Inspection By Date a ❑ WAIVER ReCei �+ ITT <br /> Soil Boring wIn�s ection By Date Constructed Well Depth ''II y�it��� ft <br /> "COMMENTS /va G IOn /V_ t� NnV a/ <br /> PE SC Received Amount Date Permit/ Invoider ONA4E <br /> Codes Info By Cash Remitted Service Re uest# <br /> V366 s 0 rl 4\24 �1P24 m123G, ENT <br /> Y392 <br /> Z IIIW14 G99AV"Ininc- <br /> EHDO43-06 04/07/2022 Pagel of 2 W P Z56 Q'1 Well/Pump Permit <br /> (f A <br />