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Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ate / le-OZ-Okrea I Employee ID# 0 <br />Date SPECIAL Well Permit <br />Date Lk („ LI W AIVER Received <br />Date <br />7pRTMENT US.E ONLY <br />ELT <br />Constructed Well Depth ft <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STocicroN CA 95205 - (209) 468-3420 <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Coe t (12 '‘,Y\AID.eirll La.n.e ciTymp 5-kcielon <br />1-Mcire,k-Ar) APN g 44" 2-01 aPAncEL SIZE ° 75 LAND USE APPLICATION # <br />-eL) LeitY Scx rialaitV <br />(alCaLt K-ryy-\\DextL, Low-ut <br />Off gA <br />Ah7cox- Roca <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS 62/c9 <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />PHONE -55/ - -7clo-311e47 <br />51Z-r-k gicti C71-91,5a/a <br /> PHONE ,920 q3/ <br />S-6 C-kfrin CAL 75c)Z5— :SS32100V 311S SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS N/A Crry/STATE/ZiP <br />PHONE <br />LICENSE p-C-57 0 C-61 0 0-09 0 Other NUMBER EXPIRATION DATE J J 4c) 3 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br /> <br />INTENDED USE ?...Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Monitoring Well(s) # of wells 0 Soil Boring(s) <br />Out-Of-Service Well <br />New Pump CIrkump Replacement 0 Pump Repair <br />ft <br />Plastic 0 Stainless Steel <br />Sand Cement <br />0 Other diRr4i0.,_ <br /> sack mix/7 gal ?r <br />#4 PR <br />0 2022 %Jai <br />QUM, FIAmeter <br />titiL/4414' <br /># of <br />A r <br />Pei? <br />i e lif414 <br />0 Retardant / Accelerator (name) <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />of borings <br />0 Geotechnical <br />0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Air Rotary 0 Auger Mud Rotary 0 Cable Tool 0 Push Point 0 Other <br />Depth ft in diameter 0 Open Bottom 0 Gravel Pack/Gravel Si Proposed Well Excavation <br />Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Sched 0 Steel Well Casing <br />Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) Grout Seal <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal ODimensions: Width ft Length <br /> ft Thick <br />in O Christy Box 0 Stove Pipe <br />PUMP <br /> kubmersibleD Turbine 0 Other <br />P I/2 Pump Set ft Standing Water Level <br /> <br />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 />mimmum 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Bv <br />c.Checict) Amount <br />Remitted Date Permit/ <br />ce Renuest # Invoice # Well ID# t-asrf <br />if -3 g1 0 50(10-- /./.2—(9 q-3— 4-1.a TP6 if\oLigigtp <br />E11D043-06 10/25/2021 Page I of 2 Well / Pump Permit