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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Ivvrv-INtrLINUAtili I'ERMIT GALL Z09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �f _�� ��p�•- CITY/ZIP953M <br />CROSS STREET,'C/ t� <br />)��Ce/ Alli -+/,� �/ 0-'z gRCEL SIZE -�: �. LAND USE APPLICATION #JU, %? <br />OWNER NAME /"lig L/n/!T!¢� �jl /�/S`S/1i PHONE <br />OWNER ADDRESS W o{ i� �,`f� /�v� / y4 CITY/STATE/ZIP <br />CONTRACTOR co(' rgjc�/��►` E PHONE { — 5O <br />CONTRACTOR ADDRESS �J� 7 7 (( pl '7�Ipuyey �J� ;?—it_ CITY/STATE/ZIP_ (�.T_ _ � 4 9�tsY5' + <br />SUBCONTRACTOR�' <br />n PHONE L I <br />SUBCONTRACTOR ADDRESS j �tiC � /c / %jy��@1i r c- CITYIScTjATE/ZIP V E35- ✓/�,_Acrv�tz� /�Q &/-A g56'Tn <br />I <br />LICENSE VC -57 C-61 ❑ D-09 Other NUMBER 6I I c% EXPIRATION DATE _ (;Ao �Z3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private . Irrigation/Agricultural _ Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />r Trt UP- "UKK u New well Replacement Well ❑ Well Alteration/Modification Other _ <br />❑ Monitoring Wells) # of wells 0 Soil Boring(s) # of borings Geotechnical ° =' of bonnas <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />- New Pump Pump Replacement 0 Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ::: Mud Rotary Air Rotary Auger Cable Tool VPush Point Other <br />Proposed Well Depth ) ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size _ in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel _- Other <br />Grout Seal Depth ?c7 f1 Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack miX17 gal water <br />Bentonite (20% solids) Other 1111P.1-41— <br />Grout <br />u,Grout Placement Method rPumped .: Free Fall V Other 1 11❑ Retardant / Accelerator (name) L"" <br />PEDESTAL Installed By - Driller Pump Contractor ❑ Other <br />L Concrete Pedestal " Dimensions: Width ft Length ft Thick <br />in C Christy Box Stove Pipe AU6 15 2.022 <br />PUMP C Submersible.. Turbine Other HP Pump Set ft Standi dZ COUNTY ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect 1 tot lIW3pt19lyitt� <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 />ALN P�tr T40!R ADN',y:�CE NOTICE REQUIRED FOR INSPECTIONS - PLE:,�L t ,til t il9j 9:i; <br />DEPARTMENT USE ONLY <br />Application Accepted By Date (� / 5 � Area Employee ID# <br />Grout Inspection By CIL <br />Date C SPECIAL Well Permit <br />Pump Inspection By Date I o _ C WAIVER Received <br />Soil Boring Inspection By DateL-�U (�i� Constructed Well Depth <br />COMMENTS <br />ft <br />PE SC Received Check#/ Amount <br />Codes Info B Cash Remitted ate <br />Permit/ <br />Service Re uest # Invoice # Well ID# <br />5� <br />EHDO43.0604/07/2022 Page I oft Well Pune Perm;[ <br />T <br />m <br />D <br />0 <br />0 <br />z <br />rn <br />