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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 46M420 <br />NON-REFUNDABLE PERMIT <br />209 953-7697 FOR INSPECTIONS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Z <br />/% c/C-A,�LQL <br />K- TM—v � /lam <br />rEAXPIRES <br />Cn <br />, <br />CITYIZZIIP��d dek"I'y% L7} . 453;4176 m <br />CROSS STREET ?2/4NAV0N <br />APN %,�4_D30 • <br />PARCEL SIZE 4f AC USE APPLICATION # o <br />OWNER NAME h�o�E2T <br />R/VD�L/it�C7/i1E� <br />-LAND <br />r/C J <br />PHONE&00 &* 7117,9 y <br />d!' <br />OWNER ADDRESS X36oc /� <br />�� R d <br />CITY/STATE/ZIP GS��} (�,t/, ( • T `� �Z� • 7 <br />CONTRACTOR2�' <br />f�/�►s NG• <br />4 <br />PHON(/ I —//'34 <br />CONTRACTOR ADDRESS Iq mak% <br />��GS r ��� <br />•//3 <br />n�^ <br />CITY/STATE/ZIP 5py&5Z r� `-`�7 /5�70 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE y( C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7 EXPIRATION DATE Z Z 51 <br />DOMESTIC WELL SAMPLING: W.,General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth41P d ft A Excavation I in diameter ❑ Open Bottom ;( Gravel Pack/Gravel Size -• IZ in diameter <br />Conductor Casing 119 in diameter / Conductor Casing Depth /,D ft <br />Well Casing Diameter 8— in Thickness/Gauge/ASTM Sched SOR 17 ❑ Steel )(Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 1-00 ft ❑ Neat Cement (94 lb bag/5-10 gal water) iJ Sand Cement sack mW7 gal water <br />X Bentonite (20% solids) ❑ Other <br />Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I;KPump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ;' Submersible[] Turbine ❑ Other HP Z Pump Set 3 VO 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 />MININAIM 24 HOUR ADVANCE: NOTICE RF.QITIRED FOR INSPECTIONS - PLEASF. CALL. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By G Date 1 Z L Area i I <� Employee ID# AG <br />Grout Inspection By AZ Date T/� ❑ SPECIAL Well Permit <br />Pump Inspection By ff56 60142,11-7 Date L7 -r- rty- ' ❑ WAIVER Received I"q <br />Soil Boring Inspection By Datelo p LLbZ�onstructecl Well Depth <br />COMMENTS 0474 1,)T t1') ReLo r Ct c LD {-N f j J 1 r-1 C; � F h G/JL 0 PSI 1n %Y/LL <br />PE <br />Codes <br />SC Received <br />Info By <br />Q ec Amount <br />Cash Remitted <br />Pe Dat It/ <br />Service Request # <br />Invoice # ✓O II ID# <br />E <br />L 80 <br />., I <br />T N,y OU <br />143 » <br />T <br />EHD043.06 10/25/2021 Page I of 2 (41 0 t-' � p �� �> ��� Well / Pump Permit <br />