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I ` WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE VERMIT GALL ZUy y03-/bUt FOR INSPECTIONS LAVIIKLb I TEAR FROM DATE ISSUED JOB ADDRESS .// 7? ILI _ .�.�. . � - � CITY//ZIP/ in I2G.r ? 9533' CROSS STREET �, Aft jL-� h c -t AP NO'- 00 PARC !J (� PARCEL SIZE 041-- c, LAND USE`9AP�P,LICCATIION #�A OWNER NAME _� C1{�pl. Vii?�¢f� >� "'✓iS/r�� PHONE (�-O'7/��(O.25-C327C,o OWNER ADDRESS W . �Csu:S1' AV,2t W CITY/STATE/ZIP ,.� C� FL(� r�7`1 1?5-33 T CONTRACTOR OGC /e �-�M/ k Q.3t` / ffPHONE filw4,d 6.3-3 - 46 CONTRACTOR ADDRESS J✓ 1 C�G�/yo� �I ��G'V IJn+r� CITY/STATE/ZIP � �. (A /q-97_5 SUBCONTRACTOR 0"A -L- W 4e � v' -i �.s PHONE 4l6) � 7i/-��I Sk Q SUBCONTRACTOR ADDRESS. 30- - 'r' 51 r ij 13-J. - CITY1S/TTAATE/ZIP ;1 �_Mvra>� �r4< LICENSE Y C-57 C-61 i- D-09 - Other NUMBER gq 1 61 EXPIRATION DATE h/310/ DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE ❑ Domestic/Private CI Irrigation/Agricultural C Industrial l7 Water Quality Monitoring _ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well - Replacement Well 1-1 Well Alteration/Modification - Other ❑ Monitoring Well(s) # of wells CI Soil Boring(s) _ # of borings /Geotechnical # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair New Pump Pump Replacement J Pump Repair Raise Well Casing Drilling Method i i Mud Rotary C Air Rotary - Auger ❑ Cable Tool V Push Point C Other Proposed Well Depth `'c I ft Excavation _ 2" in diameter - Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft PAYMENT Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel D Plastic C Stainless Steel & {� Grout Seal Depth -' ,-� ft Neat Cement (94 /b bag/5-10 gal water) 11A Sand Cement „ r � ail water 1 Bentonite (20% solids) - Other Grout Placement Method ❑ Pumped ❑ Free Fall Other . Q Retardant / Accelerator (name) AUG 15 L122 PEDESTAL Installed By - Driller ❑ Pump Contractor ❑ Other SAN JOAQUIN COU 11 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick ENVIR n I I Christy Box C Stove Pipe HFALT HDEPARIM IF'UMP i i, Submersible '_1 Turbine i:' Other HP Pump Set ft Standing Water Level 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. I INIMUM 24 HOUR ADVANCE NOTICE REQLTIRFD FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Application Accepted By Grout Inspection B� Pump Inspection By Soil Boring Inspection By COMMENTS EpARTMENT USE O L Date 3 Date Date Area �Employee ID# ❑ S ECIAL Well Permit ❑ WAIVER Received Date 'L 2 Ayl !n 1(j2Zpnstructed Well Depth ft T M D D M M PE SC Received Check#/ Amount Date Permit/ C des Info - B Cash R miffed Service Request # Invoice # Well ID# c EHDO43.06 04/07/2022 Page 1 of 2 Well / PumP Permit