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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFuND4RLF PERMIT CALL f2111191(1153.7697 FOR INSPFr:Tinhiq FXPIRFR 1 YFAR CRnu i A rF Issl IFn <br />JOB ADDRESS J oc) W ..� CITYiZ�IP Trc�C� <br />CROSS STREET Cr: S IN-c",IL11s.c ry\ APN Z 51 '�i 0 15 PARCEL SIZE "I�LAND USE APPLICATION # <br />t� Z -W - i S -I� , ZSc _IS -IL _ <br />OWNER NAME �l.cL1Cl.,wl� I unto 'f 6�rc✓i2 LLC PHONE 017S -SqP y 1-2')1 <br />Cc <br />C 1, <br />OWNER ADDRESS _ l�,CITYrISCTl ATY EiZIP -2 <br />CONTRACTOR <br />CONTRACTOR Qvryv6eJec-4c. l He 7-1,tPHONE `14,1 — 6 06, `0 3 <br />CONTRACTOR ADDRESS mo hve-)Sa .3 CITYiSTATE21P <br />SUBCONTRACTOR i1QS <br />�ecJ�•� �: ��t`�C� !T'hCYI.✓ { PHONE <br />SUBCONTRACTOR ADDRESS ?D •1 A �?�� CITYISTATE17JP Ese'(G , , C �� f~3 Z U <br />LICENSE C 57 ❑ a61 ❑ D-09 ❑ Other NUMBER C 6 ( EXPIRATION DATE rr I /S i Z <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 11 DomesticfPdvate ❑ InigationtAgricultural ❑ Industrial ❑ Water Quality Monitoring )R Soil Sampfing/Characterization <br />❑ Public Water System <br />II'dlftarent from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br />❑ MonitoringWeil(s) of wells ❑SoilBodng(s) #ofborings Geotechnical ""GrIngs <br />❑ Out-Of-Servlce Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ZLi ft Excavation b in diameter ❑ Open Bottom ❑ Gravel PacklGravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth Z S ft V Neat Cement (941b bag/5-10 gal wateo ❑ Sand Cement sack mlxf7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall Other C ❑ Retardant / Accelerator (name) i5AY <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimansions: Width ft Length ft Thick <br />�In ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level SAN,' <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: {®MP&1- <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 />IY PUAIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />tt DEPARTMENT USE ONLY {/+� <br />Application Accepted By - /— Z— Data '7 I eta Area -S �? Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By d Date _ ❑ WAIVER Received <br />Soil Boring Inspection By !iV C'''�1� Date �� —amu Constructed Weil Depth ft <br />COMMENTS <br />:NT <br />/ED <br />2022 <br />-OUNTY <br />NTAL <br />RTMENT <br />PE se Received Check#1 <br />Codes Info Cash. <br />Amount Data Permit/ Invoice# WeIIID# <br />Remitted Service Request # <br />Ak r V, <br />orU <br />EHDO43.06 04/072022 Page l .172 <br />1444 ll44y- <br />1 q � <br />dy1q�gb �l(,(�ZZ # (oaf <br />WCll / ftv Penult <br />