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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE PERMIT GALL (2U9) 95d 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1%35 S&,ATJJ .5r- CITY/ZIP l� STDGKTb � /�- r CROSS STREET (:_ �I2Ar C Q r,Cir r (,U/} %J APN I � I UD PARCEL SIZE I,'5 LAND USE APPLICATION # OWNER NAME d 11� Z $ d7 Cx ✓` A meA PHONE b9 OWNER ADDRESS j E4,� Lyc _6Py' V e. CITY/STATE/ZIP STDt K rP h,' CA 9 s Zta2 CONTRACTOR l�(1''-1 1� TA i'aMPri eLlL1 T/-,AA,/,,kJ SPI'y"(P3 J -C , PHONE 71171. 233- 4P/,& CONTRACTOR ADDRESS Su,;to 4 ( _� � P�j � � j S e LVA S CITY/STATE/ZIP { V? 6t C% _ CA � `3 94P (^�� SUBCONTRACTOR 1 / { (Jr,t I n �� PHONE li & -113— Z 3 ( SUBCONTRACTOR ADDRESS -Ms'---fes :�iT �-- 14 Al) KI CITY/STATE/ZIP C I • I`/IVYI(� G1 1`!) .. ( X71' 1 V LICENSE !WC -57 ❑ C-61 ❑ D-09 LC Other. NUMBER IDUroFy�IS EXPIRATION DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) a Arsenic (4393) 3 INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring WSoil Sampling/Characterization ❑ Public Water System KrT r1 b b51 -71-4-06(a If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Monitoring Well(s) # of wells ❑ Out -Of -Service Well ❑ New PumD ❑ PumD Replacement ❑ Well Alteration/Modification Soil Boring(s) -3 D Out -Of -Service Well Renewa ❑ P ❑ Other # of borings ❑ Geotechnical 1 D Cross -Connection Repair ❑ Raise Well Casing WELL CONSTRUCTION H/-'/? Drilling Method ❑ Mud Rotary ❑ Air Rotary )(Auger ❑ Cable Tool ❑ Push Point ❑ Other -SANd... O ��2 Proposed Well Depth 7-J>ft Excavation _ (6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size E r ❑Conductor Casing in diameter / Conductor Casing Depth ft 04MFIyT ►Y Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other KRTMENr Grout Seal Depth a o ft ❑ Neat Cement (94 Ib bag15-10 gal water) Sand Cement 10,3 sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Cif V"7T Grout Placement Method ❑ Pumped Q'Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (109) 953-7697 DEPARTMENT USE ONLY Application Accepted By �L ate D Area I �% Employee ID# Grout Inspection By�Lo_UI Date Z Z. ❑ PECIAL Well Permit Pump Inspection By Soil Boring Inspection By COMMENTS item it Date ❑ WAIVER Received Constructed Well Depth t� T PE Codes Sc Received Check#/ Info B Cash Amount Dat Permit/ Invoice # Well ID# Remitted J I ervic Request # 3-7a 15 Ste- 4760 i EHD043-06 04/07/2022 /!5w. " {y ' ,' , r 06 1 - ye 1 oft Well / Pump Permit