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ft Pump Set ft Standing Water Level Submersible0 Turbine 0 Other HP PUMP <br />Water System Name If different from Owner: Contact Name or Phone Number <br />ft Thick <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor C Other <br />Concrete Pedestal 0Dimensions: Width ft Length <br />in 0 Christy Box 0 Stove Pipe <br />NON -REFUNDA RI P PPD"RIT <br />JOB ADDRESS 1 0S-95" . : :A&A' - arazip _ t_ <br />CROSS STREET Pii Pi Ci SC° APN 04 OD • 0 PARCEL SIZE. I, 11 CI LAND USE APPLICATION # <br />OWNER NAME fil 1 an drip , G cei--ei i on PHONE Lf -444V -11004b <br />OWNER ADDRESS <br />CONTRACTOR CiA4-1-e Wal Dri (Itn b- <br />CONTRACTOR ADDRESS pl).07c tqtriko CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE )C, C-57 0 C-61 0 D-09 0 Other NUMBER10444 tli EXPIRATION CIATE ),..._ <br />DOMESTIC WELL SAmPLING:A General Mineral/Coliform Bacteria <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/STATE/ZIP <br />PHONE qv/ ov <br />PHONE <br />CITY/STATE/ZIP <br />(4391)A Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE Xpomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />TYPE OF WORK ANew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other PAYAq NE 0 T Geotechnical _REcit # of borings <br />Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing / <br />WELL CONSTRUCTION <br />Drilling Method )I(Mud o ry 0 Air Rotary 0 Auge[ 0 Cable Tool 0 Push Point 0 Other SAN <br />ENv <br />JOA <br /> . QUIN c <br />Proposed Well Depth . 0 ft Excavation fa. in diameter 0 Open Bottom Gravel Pack/Gravel • rx0 411 alYr <br />Conduct r Casing in diameter / Condu tor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sche 0 Steel Xplastic 0 Stainless Steel 0 Other <br />ft 0 Neat Cement (94/b bag/5-10 gal water) 0 Sand Cement sack mixI7 gal water <br />KL, Bentonite (20% solids) 0 Other <br />Grout Placement Method)aumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />Monitoring Well(s) # of wells 0 Soil Boring(s) 1VED <br />06 2022 <br />ft DEPARTme <br />Grout Seal Depth <br />1. WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <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 />NIININIt NI 24 HOUR ADVANCE NOTICE Rrot ARE° FOR INsPI CTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By"------)Z Z- /__ Date //C/) Area Employee ID# FIGI rik <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By 4)4,4,,u.... Date % III) n.- 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />ReceivedCIC„ -ej j2j , <br />Cash _ <br />Amount <br />Remitted <br />Permit/ <br /># Invoice # Well ID# <br />LIY.G NO Z /4 /3`t5 4 '1(20 <br />Die <br />1 0 4. <br />Arv'etei.Request AI <br />l43 'I <br />/f/ <br />.i• 15 0 u I i <br />1-134,7. 0 $ 14( *70 v 1 i <br />EHD043-06 10/25/2021 <br />Page I of 2 <br /> Well / Pump Permit