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1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)466-3420 NON-REFUNDABLE PERMIT CALL��953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED _ In JOB Anoaess �► E EI. �a R A D a ST CITY/Z,P S Ta�K T!>1�/ g 5 i o 3 �mDDi CROSS STREET E J Q rb K A ST APN i41-06'2- -J7^ PARCEL SIZE 01'• LAND USE APPLICATION(I A OWNER NAME HOUS116 NX06KI7r f YHC Coll-ATY bf SA14 �DiknulM PHONE 2t440-EbyL OWNERADORESS 2575 6AA&ID- LAtUftL. $6tiLEVA60 _ CITY/STATEIZIP �iB'i-�"f0►J/4/�f hS Lt)7 CONTRACTOR ' AAA- .bPe 6twfJEfR1FJG LgID�lt?681 5, !NG• PHONE �fL-375' 6766 C'iONrRAC70R ADDRESS 601 '6 it'CLX rr �``I1�E CITYISTATFIZIP 5A�RA Nt�.N"1'h1 t-A 5 g(I SUBCONTRACTOR _V4-W Y P,ILL 1 N V�uI�J� c PHONE q SUHCONTRACTUR ADDRESS 113"syL A r"K rl uF`S 1 D h CITYISTATEIZIP 6 ALT/ CA f r S� �2- LICENSE LfCENSE $C-57 D C-61 11 D•09 ❑Other NUMBER -72-0101 EXPIRATION DATE DOMESTIC WELL SAMPLING:O General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDFO USE 11 Domostic/Prlvatc U Inigalion/Agricuilural D Industrial ❑ Water Quality Monitoring 1!.Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System ame Cooled Nemo or Phone Number TYPE OF WORK O Now Well o Replacement Well ❑Well Alterall....rr.I...lai-11— D Other D Monitoring Wer(s) #of walla I(Soil Boring( At of bo"n93 Ir Geotechnical 2 n of borings D Out-Of-Service Well D Out-Of-Service Well Renewal D Crass-Connecfion Repair _U New Pump ti Pump Roplacomont ❑Pump Repair D Raise Well Casing N{ELL CONSTRUCTION Drilling Method ❑ Mud Rotary D Air Rotary 9 Auger D Cable Tool ❑Push Point U Other Proposed Wall Depth S(I it Excavation _%__ In diameter U Open Bottom ❑ Gravel Pack/Gravel Size In diameter ❑ Conductor Casing__ __ in diameter I Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel D Plastic U Stainless Steel D Other Grout Seal Depth `> it VNeat Cement(94)b bag/5-10 gal wafer) D Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) D Other Grout Placement Method Ili Pumped D Free Fell U Other _❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller U Pump Contractor D Other LI Concrete Pedostal TlDimenslons:Width fl Length it Thick In U Christy Box 0 Stovo Plpo — - —— - — Water Level K IPuatr U Submersible❑Turbine D Other HP Pump Sol h Standing Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following Items. GPS Coordinates, property tines, 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 tines. For Domestic, Agriculture,Industrial well,provide location of any water weUs or surface water within 200'radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)957-7697 DEPARTMENT USE,ONLY NA Application Accepted By X11 Dale �� )� '� / Area�s64 Employee ID# �J+' EIVED/1 Grout Inspection By _ Date ❑ SPECIAL Well Permit Pump Inspection By _ Date ❑ WAIVER Received 9EC 3 202f Soil Boring Inspection By (i.1 a 1i i Dale Z Constructed Well Depthpp 'Dn wN COUN7V' ENVIR NMENTAL COMMENTS PA RiMEN7 - PE S Received Check#! aunt eReq Invoice# Well ION Codes Info B Cash Remitted ZAV te erylce Request# i 37d ISS `t' v I r.IlDal1-os ior:vmzl � r �,c� b /�9/ a°I orzC'q J t Gto