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�. WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln JOB ADDRESS o q 7 C.rQ CCS f r o �-o it I?�' CITY/ZIP ( cyj h m zy.� D CROSS STREET �O//,, APN 7 PARCEL SIZE Ib LAND USE APPLICATION# z OWNER NAME N ! J �C-1 A l 1H t Ir�` `p A PHONE 04-t-11— (��&z—]V(�,i2q N OWNER ADDRESS t L��"l�� l�' CITY/STATE/ZIP M 14 11 1�l CA, q ✓✓�F� CONTRACTOR V1r� { {�V I ,(I��( ht ,, 1 PHO/NE-20(5i),Gy�g of p CONTRACTOR ADDRESS V `o,— 1 —1 � Y/ CITY/STATE/ZIP`zt t'• y%� r r, SUBCONTRACTOR I PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER I uy Lt`s "' EXPIRATION DATE DOMESTIC WELL SAMPLING:General Mineral/Coliform Bacteria(4391)Dibromochloropropane (4392)i i Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK *4 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud t Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation I in diameter ❑ Open Bottom )ILGravel Pack/Gravel Size in diameter ❑ Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter i�{ess/Gauge/ASTM Sche El Steel APlastic ❑ Stainless Steel ❑ Other Grout Seal Dept. b ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Apumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) pMMENT PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other RECEIVED ❑ Concrete Pedestal El Dimensions:Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to thef iw '*S Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existii pTldt�ili �1T 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. VINI\II V 2-1 IIOt R \I)\,0( F NO 1('IC RI(()[ IFZI:1)I OR 1A1`11E( I IONS-PLF:ASI:( \1.1.12()'1)');3-'69" r� DEPARTMENT USE ONLY Application Accepted By �/�G L Date -9/9,6`2 Area S Employee ID# Grout Inspection By k Date 2.1 a2 22 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Re uest# 3 46 J90 �yl/ : 9 Do Lf 391 so 2'2.2 Z 3qa 2•Z• 22 2-1 qq ERD043-06 10/25/2021 Page I of 2 Well/Pump Permit