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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 / ❑ Other X10) CITY/ZIP ��— / 7 �/ U N m m �t CROSS STREET /I/ e//�� /.y C AI'JO �V&^ /d(_ 7y PARCEL SIZE LAND USE APPLICATIO/N�## D OWNER NAME El Raise Well CasinoRONME PHONE( �+'"[� —!A✓Z� tin OWNER ADDRESS /��/� /Vli/�'/�,l A4!0 CITY/STATE/ZIP �'�(/ j/��Cf�':�M e5yk /'Z ❑ Conductor Casing in diameter / Conductor Casing Depth q/'.�r� CONTRACTORf, Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel t2 PHONE Grout Seal Depth / 3'5'*)— ft ❑ Neat Cement (94 Ib bag/5-10 gal water) CONTRACTOR ADDRESS / /�L'�/F /,�1 CITY/STATE/ZIP •,✓%''/ /I " / / Z Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant SUBCONTRACTOR PHONE 'ice SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other CITY/STATE/ZIP_ NUMBER � (_0 D X � W EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) r Dibromochloropropane (4392) r Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Chars ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone N r TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical o n 22 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ElCross -Connection Repair �QUIN CO El LINTY Pum [IPum Replacement ❑ Pum Repair El Raise Well CasinoRONME WELL CONSTRUCTION ARTMENT Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ElPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth / 3'5'*)— ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe 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 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT �Ua E ONLY Application Accepted By � Date C� S a� Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS Abe,' J yaiys niz1PC or' rz;,o rSk r,f vvelt Area qC% Employee ID# F& ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE SC Received hec Codes Info B Amount Date Remitted Permit/ Invoice # Service Request # Well ID# 17 94Taa S 2 ? c�o�135t - EHD043-06 04/07/2022 Page I of 2 Well / Pump Permit