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I WELUPUNiP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NVN-KEFUNDABLE PERMIT GALL (ZU9) yb3-1bV1 FOR INSPECTIONS tAPIKtS 7 YEAR FROM UATE ISSUED JOB ADDRESS `)301 N - 4c,+ct 4 *vf CITY/ZIP , C!'e o,✓ 4� 3 C 6 CROSS STREET LIU. A +IIV ' /XT APN 2rrf - o pro' /119 --0y PARCEL SIZE LAND USE APPLICATION # OWNER NAME R►pt/✓/V�eF�E� �Gk�� la�1%'srPHONE OWNER OWNER ADDRESS/30 /'C� C/%J R✓(} CITYISTATE/ZIP/(J, CONTRACTOR CONTRACTOR ( 4 L C E 1yw, V t9'Ij O c I -i ff PHONE (/ /(J (^ T CONTRACTOR ADDRESS 7OrO ✓�✓AVJy4 J* - �LVy CITY/STATE/ZIP afir.J4cc"t.►,o, CA' qf6 ? 1 SUBCONTRACTOR M l D DL l` G t4l H 4/n T&S�1^/S IJV c • PHONE (11 Y) 6 zr SUBCONTRACTOR ADDRESS 23SW t fAV T 0"P 11. 1/1-V2- CITYISTATE/ZIP Kt* V''gLO , � � Q'/f LICENSE Y C-57 L C-61 _: D-09 -' Other NUMBER 15 f 9 y+/ EXPIRATION DATE 70 DOMESTIC WELL. SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromoch lo ro propane (4392) Arsenic (4393) INTENDED USE ❑ Domestic/Private '_I Irrigation/Agricultural Industrial L Water Quality Monitoring('Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contac: Name or Phone Number TYPE OF WORK ❑ New Well f Replacement Well 1 Well Alteration/Modification i i Other _ ❑ Monitoring Well(s) # of wells [i Soil Boring(s) _ tt of borings Geotechnical 2_# of borings ❑ Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair _ New rump i rump Kepiacerrent rump txepalr _ u Kaise vven uasmg WELL CONSTRUCTION Drilling Method _i Mud Rotary [ I Air Rotary I Auger Cable Tool ?(Push Point Other _ Proposed Well Depth TO ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size in diameter LI Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTR1 Sched Steel Plastic Stainless Steel Other Grout Seal Depth j -e ft X Neat Cement (94 Ib bag15-10 gat mater) Sand Cement sack mix/7 gal water I_ Bentonite (20% solids) Other Grout Placement Method Pumped . Free Fall ,4 Other Tits +►l It Retardant / Accelerator (name) (PEDESTAL Installed By Driller Pump Contra:tor Other ❑ Concrete Pedestal Dimensions: Width ft Length ft Thick In ❑ Christy Box Stove Pipe PUMP ❑ Submersible. 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, Nvater 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 evater within 200' radius of proposed well. ��j l DEPARTMENT USE ONLY Application Accepted By "— /�yZ-- Date � 7 as Grout Inspection By Date Area S � I n Employee IDti & ❑ SPECIAL Well Permit Pump Inspection By _ Date _ ❑ WAIVER Received Soil Boring Inspection By Date /bZ7"/V1/0 Z�onstructed Well Depth COMMENTS ft O A M y PE Cc -des Cc -des SC Received Check Amount Date PermiU Invoice # Info B Remitted '-R UeSt # 1 SU O Z ZZ CV Well ID# w3701 _ I i EIID043-06 04;07%2022 N_';. I ot:i %t,,: --r r 1', n v