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I ' WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VEpRMIT GALL (YUU) y03-/py/ FOR INSPECTIONS t:YVlKtb 7 YEAR FROM UATE ISSUED <br />JOB ADDRESS Z92 ( (��DF�Ov.G'i 4�/ CITY//Z/IPP %.5 C WLKi'O"/ lfjL/2 <br />CROSS STREET �0 [ Y4 -'F, /� APN 00 - VYO- 070 - 04PO PARCEL SIZE 7v ' r LAND USE APPLICATION # <br />OWNER NAME $--road?., <br />rc/' 0I (, �11?titGT <br />PHONE <br />N3�a so <br />OWNER ADDRESS / /y • �I'/ +�Q/f0/'� <br />/' <br />CITY/STATE/ZIP i <br />C _4 f12- 0 2 <br />170 <br />CONTRACTORy" ii�ii C� ` �VL� /i <br />0 elsf B G (4141 <br />PHONE(9/ b-0 <br />?12, — I'l it <br />CONTRACTOR ADDRESS 3AJ D 1,V P&1Twr4s. &V9 CITY/STATE/ZIP I* !'r'C .' C4 i r6 fl <br />SUBCONTRACTOR V$' k W <br />q )2/Vnb(/t //^PHONEC� �17 r/ 7 - 7700 <br />i) <br />SUBCONTRACTOR ADDRESS // U L4(k Royil R2 CITY/STATE/ZIP ll_�i C4 9 _C ` .? Z <br />LICENSE -XC-57 C-61 D-09 Other <br />NUMBER 72V ?19 7 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 11 General Mineral/Coliform Bacteria (4391) l I Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private I Irrigation/Agricultural FlInclustrial ❑ Water Quality Monitoring ?(Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well Replacement Well E Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells E Soil Boring(s) <br />❑ Out -Of -Service Well E Out -Of -Service Well Renewal <br />17 New Pump I Pump Replacement Pum <br />I Other <br /># of borings VGeotechnical .2 # of borings <br />Cross -Connection Repair <br />[ i Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary I Air Rotary 'Auger C Cable Tool Push Point ❑ Other <br />Proposed Well Depth / o ft Excavation 6* ' in diameter ❑ Open Bottom Gravel Pack/Gravel Size i®t1»t <br />"^ er <br />Conductor Casing in diameter / Conductor Casing Depth ft RECEIVED f�i <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched [ISteel Plastic Stainless Steel Oty+E�VED <br />Grout Seal Depth /S fo ft ❑ Neat Cement (94 Ib bag/5-10 gal water) I- Sand Cement sack mix177 gal water <br />' Bentonite (20% solids) ❑ Other 1111 2 <br />Grout Placement Method C Pumped Free Fall )(Other T26M (12 Retardant / Accelerator (name) <br />PEDESTAL Installed By 11 Driller ❑ Pump Contractor D Other ENVIRONMENTAL <br />❑ Concrete Pedestal ❑Dimensions: Width __ft Length ft Thick HE_'_ T`-! D=f:�a.RTArEN fj <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible_ Turbine Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: 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 />MINIMUA -t HOUR ADVANCE NOTI E REQUIRED FOR 1NSPE PIONS - PLEASE CALL (2 ) 953-764 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />_7 Z_ Date <br />Date <br />Date <br />Date Z,2 <br />Area Sl a-k}O), Employee ID# Fr4yt k <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info <br />Check#/ Amount <br />h RemittedService <br />Date Permit/ Invoice # Well ID# <br />Request # <br />N3�a so <br />46�i_712,74Z <br />EHD043.0604/072022 Pa_- 1 0'- \DCII Pump PCIMIt <br />