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1 WELL/PUMP PERMIT �;AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL` 209 953-7697 FOR INSPECTIONS /EXPIRES 11 YEAR FROM DATE ISSUED JOB ADDRESS / /G'—� r� �`' CITYIZIP CROSS STREET �� APN Q D rJ7 O $C7O PARCEL SIZE , Oq LAND USE APPLICATION # G 7 OWNER NAME¢¢/L//G ` PHON��/ OWNER ADDRESS /py'` �� /, �/ '�Z� �CITY/STATE21P /rl�` /)e ----S, G_ rl d CONTRACTOR > o [c //( l'� /� [� e -4r L ✓ rCG /1/ �lPHONE G 4� CONTRACTOR ADDRESS �L L� CITYISTATE/ZIP SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE I:! C-57 `4i' C-61 -, D-09 ❑ Other_ PHONE CIITYISTA(T,E21P / NUMBER <53 /7o EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE � Domestic/Private I ; Irrigation/Agricultural [: Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization El Public Water System If different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well I Replacement Well ❑ Well AlterationlModification 1 Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal i 1 Cross -Connection Repair ❑ New Pump XPump Replacement ❑ Pump Repair I I Raise Well Casing ' V WELL CONSTRUCTION 9 Drilling Method Mud Rotary Air Rotary ❑ Auger Il Cable Tool i:] Push Point I I Other / SQN�C �!Q Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Grave 8d0meter ! Conductor Casing in diameter / Conductor Casing Depth ft "Cp�RNT �NTy Well Casing Diameter _ in Thickness/Gauge/ASTM Sched C7 Steel I I Plastic ❑ Stainless Steel Cl Other Grout Seal Depth ft 1.1 Neat Cement (94 Ib bag/5-10 gal water) I 1 Sand Cement sack mix/7 ga water I! Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped 11 Free Fall Cl Other I_ I Retardant /Accelerator (name) PEDESTAL Installed By I 1 Driller I_! Pump Contractor I_: Other ❑ Concrete Pedestal !!Dimensions: Width ft Length ft Thick in ❑ ChristyBox I Stove Pipe Pump Submersible❑ Turbine [l Other HP Pump Set d_2f ft Standing Water Level e L 7 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. NIMNIUAI 24 HOA g2 ADVANCE. NOTICE. REQUIRED FOR INSPEc'rIONS - PIXASE CALL. (209) 953-7697 DEPARTMENT USE ONLY (� Application Accepted By Date Area / Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By v C� Date Z(i� �"� ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth It COMMENTS 9CY1�Icyor ine4 s�f�el��l�jLj l k T 1 M D rn H PE SC Received Chec Codes Info B - as Amount Date Remitted Permit/ Invoice # Well ID# rvice R nest # Y391 OSa 7 7 Lt 222 0� EHD043-06 10/25/2021 %�y Pag, 1 of 2� Wen i Pump Permit 7S�