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rr 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLEtPERMIT (�t:ALL ZU9 y93-1bVf FOR INSPECTIONS AhAF'IKt, 'I YEAR FROM DATE ISSUED p JOB ADDRESS %/600 /��CQ/ •'1 ��eX CITY/ZIP / "/ ��1 �� 9 5 ??(' CROSS STREET oC C ryp�y I� rh' :J� APN .^C P��'�l; l0 - L7 AJC PARCEL SIZE IG. �S ,,.LAND USE APPL11CACT'ION # OWNER NAME PHONE OWNER ADDRESS Z-2- "1 VJ .Co. esti /g�.erw CITY/STATE/ZIP •� Lw�7ec �.� CA 7533 7 CONTRACTOR V"{ I i p / /�PHOONE �ZO�`� 67 - �70J CONTRACTOR ADDRESS /�i�3 /j � ��c�Ch�.(�rS �a rv�. CITY/STATE/ZIP (yLJr� (� 1�5��< `I SUBCONTRACTOR I��J It�e2r-',' / �u(.) � /`�iSSG, j,-4, 1 PHONE 616)j 5.72 (' I�'I s 7 SUBCONTRACTOR ADDRESS X050 Ln W:l r�u� ��'�l¢v•SC{ CITYY/SST�ATE/ZIP [11 f rt n ti,JPr� lAJi 56 I LICENSE VC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7,2 CT`I EXPIRATION DATE 'Y/3L,/_ZR DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical 41 4 of borings [I Out -Of -Service Well El Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pum WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 'o ft Excavation " in diameter ❑ Open Bottom 11Gravel Pack/Gravel Size in diameter ElConductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ,<_O ft Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped El Free Fall Other o, �. ; ❑Retardant /Accelerator (name) �AVRlI�*az�r^x- PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other RFGE1 Z12 ❑ Concrete Pedestal CDimensions: Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe It r PUMP ❑ Submersible ❑ Turbine ❑ 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 tif� MZs":' GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, �iLr>pg Mures, 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. MININIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By Date 2 Area❑ SIF lqqEmployee ID# Grout Inspection By Date PECIAL Well Permit Pump Inspection By Soil Boring Inspection By COMMENTS Date I `;- ❑ WAIVER Received Date Ay) (n�'I_ Constructed Well Depth PE SC Received Check#/ Amount at Permit/ Invoice # Well ID# Codes Info a Remitted Service Request # 3 Lz ft ERD043-06 04/07/2022 Page I of 2 Well / Pump Permit m D D O m fy/!