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I WELL/PUMP PERMIT SAN 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 1 YEAR FROM DATE ISSUED JOB ADDRESS —5 �Il Ile"I , a 171 yr 1� CITY/ZIP LL It 1 (� `� L CROSS STREET Ili' I�C]` �I (�� K/V - AP OS 9 NAR PARCEL SIZE i SD LAND USE APPLICATION # OWNER NAME�r ��j , I ro I PHONE OWNER ADDRESS 5 L —T nnf /�I CITY/STATE/ZIP Q / `E- CONTRACTOR C. j 1 J` ^n7 rf!JS ��/ .M t� —Se ryi c PHONE PV/) / % ,5-- ,;tCJ F CONTRACTOR ADDRESS J ✓ / - { 11 Lt� CITYISTATE/ZIP�`�_ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS ' CITY/STATE/ZIP LICENSE r -57 ❑ C-61 u D-09 L. Other NUMBER �S`j D 67 EXPIRATION DA DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ""Momestic/Private G Irrigation/Agricultural ^. Industrial C Water Quality Monitoring .1 Soil Sampling/Characterization C. Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK -- New Well C Replacement Well E Well Alteration/Modification C Other T m 0 cl M w C Monitoring Well(s) # of wells ❑ Soil Boring(s) of boring' ❑Geotechnical 9 of bon g �y A , Out -Of -Service Well Out -Of -Service Well Renewal 0 Cross -Connection Repair '^V 912INeW Pump L Pump Replacement C Pump Repair -1 Raise Well Casing Drilling Method C Mud Rotary ❑ Air Rotary L Auger J Cable Tool E Push Point ❑ Other SAN JO U Proposed Well Depth ft Excavation in diameter G Open Bottom :i Gravel Pack/Gravel SizeA/ ,. Conductor Casing in diameter / Conductor Casing Depth ft �`*r5 Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ^ Steel 7 Plastic C Stainless Steel Other Grout Seal Depth it � Neat Cement (94 lb bagl5.10 gal water) ❑ Sand Cement sack mW7 gal water NT n Bentonite (20% solids) 71 Other Grout Placement Method C Pumped ❑ Free Fall C Other a Retardant / Accelerator (name) PEDESTAL Installed By J Driller D Pump Contractor C Other 11 Concrete Pedestal 'Dimensions: Width ft Length ft Thick in I Christy Box C Stove Pipe �F MP YSubmersibleC Turbine Other HP it Standing Water Level I/2 N Plot Plan Redulrements: 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. MINIMUM 24 I1OUR ADVANCE. NOTICE REQUIRED FOR INSPECHONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY (� Application Accepted By �%� r L Date s� "? Area Employee ID# 1 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By , }ir �L (. L Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS fir 1,,/ g v JP i f ,Dr' f r^ i Uri p' o-13 o'er 0 t( l l PE Codes Sc Received Check#/ Into B Cash Amount Date emitted Permit/ Service Request # Invoice # Well ID# 3,VO ,�-� S.?•Q� 2Z ,L , EHDO43.06 10 25R021 Page I of 2 �l�lO�{SS/7 Well / Pump Pernw