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1 ` WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUN(DABLE PERMIT SC Received Check#/ Amount ate Info B Cash Remitted LU�J U0J-fbUf FOR INSPECTIONS "I YEAR FROM DATE ISSUED JOB ADDRESS (SIJ I V3 /nUALL rtkf LLtAl`IKtJ E� CITY/ZIP STUf��1V'•/1 INA CROSS STREET APN 111-13p-1 j1 PARCEL SIZE +-'� LAND USE APPLICATION # OWNER NAME ZL k (, 1 -61 �Ot�V(J�^ V PHONE pl 6--3-yi ^ -3q y OWNER ADDRESS / (�+�/p�tRj( 1 /) st'ar'!1.., CtUV CITY/STATE/ZIP 50'(ZC' g4r7OG�I—gA!5y-iL�'\] CONTRACTOR jSSs PHONE ;t(% FO I ( -�-� (fe'uj I C%1 I1 CONTRACTOR ADDRESS it CITY/STATE/ZIP I SUBCONTRACTOR -L;fl(- �Y/l� P& fIG)fIQQ(1�1(�� PHONE -0 SUBCONTRACTOR ADDRESS `v �VY��+�fnG4 (y (� C� D(,'VC- SIC- 'St AC-) GIITY/STATE/ZIP 0i ,fL,ry1Q,�(I•o ��/b�1 /02 (CA lei S �(�5 LICENSE A C-57 ❑ C-61 C D-09 ❑ Other NUMBER Von(- EXPIRATION DATE 61-3(0-0-S DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural Industrial Water Quality Monitoring If Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well i Replacement Well ❑ Well Alteration/Modification ❑ Other �^ ❑ Monitoring Well(s) # of wells [I Soil Boring(s) # of borings �4 Geotechnical J # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal _I Cross -Connection Repair I New rump i_. rump Kepiacemem i i rump Kepair _i Kaise vveil WELL CONSTRUCTION Drilling Method ❑ Mud Rotary it Rotary b9 Auger I I Cable Tool I I Push Point Proposed Well Depth �5 t Excavation `; in diameter ❑ Open Bottom ❑ Conductor Casing in diameter / Conductor Casing Depth Other Well Casing Diameter in hickness/Gauge/ASTM Sched ❑ Steel I Plastic Grout Seal Depth 2 re t Neat Cement (94 Ib bag/5-10 gal water) I Sand i J Bentonite (20% solids) ❑ Other Gravel Pack/Gravel Size in diameter _ft I Stainless Steel ❑ Other Grout Placement Method [i Pumped A Free Fall A Other ' t(42 ►nw1+e 1 I Retardant / Accelerator (name) PEDESTAL Installed By 11 Driller ❑ Pump Contractor F Other I -I Concrete Pedestal ❑Dimensions: Width ft Length ft Thick n ❑ Christy Box ❑ Stove Pipe sack mix/7 gal water PUMP ❑ Submersible _I Turbine ❑ Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. NIININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 / DEPARTMENT USE ONLY }�j,} / Application Accepted By sl L— Date % ,'" t :c 5 � Area � K ` Employee ID# ( 7 Grout Inspection B / Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By COMMENTS _�Liyl_YY+LI Well Depth N mm D 0 0 X N N PE Codes SC Received Check#/ Amount ate Info B Cash Remitted Permit/ Servicea ue t # Invoice # Vp 37a b0 1A V i 8AL INA ICU F qQU '9R hr EffD043-06 10/25/2021 13 _'Jq --H-+32of 2 Well / Pump Permit �avq -:�60(5�