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1� WELL/PUMP PERMIT <br />SATS JOAwm CouNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFuNDABt_E PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FRom DATE ISSUED <br />JOB ADDRESS / / .�f�1� CmrrzlP} <br />CROSS STREET <br />/ V APN PARCEL SIZE • ( '1 e LAND USE APPLICATION # ��j –7 % yLES /!�/G /T/V/T /7 PHONE 221 •-2.31– / 4 / 1 <br />OWNER NAME <br />OWNER ADDRESS � s2L CI YISTATE/ZIP <br />CONTRACTOR 1'7C>L�4:_:7 ` <br />CONTRACTOR ADDRESS /G 7U <br />SUBCONTRACTOR ADDRESS <br />�Mt�Af ui� <br />S ///v/v Z6 <br />LICENSE ❑ C-57 k C-61 n D-09 <br />D <br />V6 JJ //,,P140HjE z�1! js /7 —�J//% <br />CITYISTATE21Py� / G-L� �./�/�/ " / ��• <br />PIS <br />CITYISTATEIZIP <br />NUMBER ,5 — EXPIRATION DA <br />.W <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) O Arsenic (4393) <br />INTI=LADED USE XDomesbcfPmate -1 ImigationtAgricuttural C' Industrial L_ Water Quality Monitoring Ci Sod SampkWCharacterrzation <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK -' New Well ❑ Replacement Well LI Well Aiteration/Modification ❑ Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />n.4 nc c....s—rabn a n C_r0SC_Cnrmx nn Repair <br />_IFo1-wpsV�D <br />Ad A t. _ Y c <br />New Pump NumpReplacement ❑ Pump Repair n Raise Well Casing <br />Vf <br />WELL CONSTRUCTION N <br />f EN Rp UIN CO <br />Drilling Method Fi Mud Rotary [I Air Rotary Auger ❑Cable Tool l.i Push Point C' Other is kEe ��li4@ <br />Proposed Well Depth ft Excavation in diameter I-1 Open Bottom L� Gravel Pack/Gravel Size d P� ameter <br />Conductor Casing in diameter / Conductor Casing Depth ft l �rEN7 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel 0 Other <br />Grout Seal Depth ft u Neat Cement (94 /b bagt5-10 gal water) o Sand Cement sack mixf7 gal water <br />❑ Bentonite (20% solids) Ii Other <br />Grout Placernent Method ❑ Pumped ❑ Free Fall III Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By : Driller 1 Pump Contractor Otter <br />r t Concrete Pedestal oDImensions: Width ft Length It Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />J111P Submersible Turbine U Other HP Pump Set _ft Standing Water Level /—'0 ft <br />Plot Plan R uirements: 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 />DEPARTMENT USE ONLY <br />Application Accepted By =:=;F_ /__/' Date s as" as <br />Grout Inspection By A A Date <br />Pump Inspection By Date 7i <br />Soil Boring Inspection By _ nP <br />COMMENTS DOCW10le" <br />W <br />Area 7 / Employee ID#E & <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructeo Well <br />\ - i'L k , I - <br />rt <br />w <br />m <br />N <br />Z <br />MID043-0610125/2021 Page I oft \yellI Ranppe tut <br />