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Y WELL/PUMP PERMIT 'fT ZZ Sa S� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT ( r /� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1YEAR FROM DATE ISSUED JOB ADDRESS 6 SSU EAS > I haat, 12- CITY/ZIP LA; C 44 Lt q-I -6- 14.7 acres CROSS STREET N kQI1(1I Son Ln APN -lam'+� O PARCEL SIZE LAND USE APPLICATION# o OWNER NAME ��-i i'�L�� 14 [ ✓'U''�� pLL /PHONE v(i' \1 OWNER ADDRESS -T�Q `' � L ! .� V"x 3 O CITY/STATE/ZIP CONTRACTOR l�fi�CJV� l G/tSl�L'�ti•t l LC_ PHONE I CONTRACTOR ADDRESS ICL Zrt Jii>tf'� W e"-I 1 j CITY/STATEIZIP LGIGI I CC'S l q-S7-4r; �7 L SUBCONTRACTOR N12i GIC'. A�uier-SIr) Lti�G� I5SJL'C'td'S +-V1C�-, PHONE SUBCONTRACTOR ADDRESS (��C I S f`I dgC,r,CW CITYL/STATEIZ/I,P t✓l Ctt�cZ /10, / 6 6 c 6 LICENSE V C-57 C C-61 C D-09 F. Other NUMBER v G 0 7 EXPIRATION DATE s 7 1 r ZL Z DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USE G Domestic/Private C Irrigation/Agricultural C Industrial C Water Quality Monitoring )Z Soil Sampling/Characterization L Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK U New Well L Replacement Well ❑ Well Alteration/Modification L Other ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 'Geotechnical 6 s of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repairb C� New Pump 0 Pump Replacement CI Pump Repair 0 Raise Well Casing WELL CONSTRUCTIONJEF/V�^ Drilling Method L Mud Rotary L Air Rotary k(Auger L Cable Tool L Push Point L Other L Proposed Well Depth J�;-30 ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel SizeMr lameter L Conductor Casing in diameter / Conductor Casing Depth ft SAN jo A Well Casing Diameter in Thickness/Gauge/ASTM Sched L Steel ❑ Plastic L Stainless SteA N Grout Seal Depth ft ;9 Neat Cement(94/b bag/5-10 gal water) L Sand CementD. rNri I water L Bentonite(20%solids) L Other r�ryENT Grout Placement Method G Pumped 0 Free Fall ❑ Other G Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor C Other 0 Concrete Pedestal ODimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe PUMP L SubmersibleL Turbine U 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: CPS 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. NIINIMUNI 24 HOCK AD%ANC'E NOTICE REQUIRED FOR INSPECTIONS-PLEASE C.-+,L1,(209)953-7697 DEPARTMENT USE ONLY ll Application Accepted By �,,rr I L ate S C a s Area i qq Employee ID# Fl e'llK Grout Inspection By �/ // l_ Z rf V Date_�� %(.2- ❑ PECIAL Well Permit Pump Inspection By Date Ll WAIVER Received Soil Boring Inspection By Date , Constructed Well Depth ) 'ft COMMENTS Tfcnn ii to be IIJ� �� (' FP�P* ��?GIN �0 C'P& o; , rl fo.nL�I,J'-4 15 � hcJL'�TPITC PE Sc Received CChecWki Amount Date Permit/ Invoice# Well ID# Codes Info as Remitted Servi a Request# 3-7a 160 X114 1a) 6 Y FHIX43-06 W 072022 Page 1 w 2 Well'Puna'Permit