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I WELL/PUMP PERMIT SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN -REFUNDABLE PERMIT Ave,GALL (ZU9) 953-7697 FOR INSPECTIONS tXPIKt5 1 YEAR FROM DATE ISSUED JOB ADDRESS i 55� Leio, AI..� CITYIZIP 9-100 A 1 CA CROSS STREET N, �IQOn r�P . A P N 19I 'D PARCEL SIZE r 7 LAND USE APPLICATION # OWNER NAME PHONE OWNER ADDRESSIlISS1 lS✓y4 ASC__ CITYISTATE/ZIP (ZypL)y, CA c953CD6o l' CONTRACTOR � alft G(o6n.cten ='M4l. -hoil 3 Te, C_ _ .. _ PHONE ZD9 - IIS- &Z.700 1 CONTRACTOR ADDRESS ISI OO S. 2G o_- T1 ""e, f�_A • CITYISTATE/ZIP /' /, I QA -"CCA t VALnf !S33G SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE U C-57 X C-61 a D-09 II Other PHONE CITYISTATE/ZIP NUMBER 109 2� I U EXPIRATION DATE O 13 1 ZD ZZ_ DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE I I Domestic/Private Ix' Irrigation/Agricultural ❑ Industrial I_I Water Quality Monitoring Il Soil Sampling/Characterization IJ Public Water System If different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK New Well I_! Replacement Well L' Well Alteration/Modification ❑ Other II MonitoringWell(s) #of wells ❑ SoilBoring(s) #ofborings Il Geotechnical 11 Out -Of -Service Well ❑ Out -Of -Service Well Renewal CI Cross -Connection Repair X New Pump 1. Pump Replacement ❑ Pump Repair I1 Raise Well Casing WELL CONSTRUCTION ' Drilling Method L1 Mud Rotary I i Air Rotary i Auger I Cable Tool L I Push Point 11 Other FiF Proposed Well Depth ft Excavation in diameter (J Open Bottom Gravel Pack/Gravel Size [J Conductor Casing in diameter / Conductor Casing Depth ft It of born, NP �9A n, RAN Well Casing Diameter In Thickness/Gauge/ASTM Sched t -I Steel LI Plastic I i Stainless Steel I Other �N Grout Seal Depth ft II Neat Cement (94 Ib bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water I I Bentonite (20% solids) LI Other Grout Placement Method 1) Pumped 0 Free Fall Il Other I I Retardant / Accelerator (name) PEDESTAL Installed By Il Driller 3K Pump Contractor ❑ Other *f Concrete Pedestal UDimensions: Width N ft Length_ ft Thick n u Christy Box ❑ Stove Pipe -trj PUMP I I Submersible Ll Turbine Cl 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, A(yriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. ;N1ININIUNI 24 HOUR ADVANCE NO 1'ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By / Z_ Grout Inspection By Pump Inspection By Soil Boring "In'spection By COMMENTS t�-N, I ,tilt' I) !til PJC' `JrY�i 5 6, s=SbvE NA. - Date 3 '9')da Area 5 Cl Cf Employee ID# Date ❑ SPECIAL Well Permit Date Z ❑ WAIVER Received Date Constructed Well Depth Y1 (of'."" I�1Ji(1 ft PE Sc Received Codes Info 8 Y., Check#/ Cash Amount Date Remitted Permit/ Invoice # Service Request # Well ID# HH0043-06 lo.'21,^021 I'.gc 1 or 2 well Pu„q, I ri n,l,