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r i ' WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 �NONREFDABLE PERMIT CAL �209)53-76�FORINSPECTIONS c EXP R S 1 YEAR FROM DATE ISSUED JOBZD�RESS CITY/ZIP < 1�rJ CROSS STREET�L OWNER NAME OWNER ADDRESS A CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS `APN _-� +�! PARCEL SIZE v LAND USE APPLICATION # e PHOCITYISNE �O [ �� - �1^ TATE21P LICENSE 4 C-57 C! C-61 ` D-09 D Other CITY/STATE/ZIP PHONE CITY/STATE/ZIP NUMBER /b EXPIRATION DATE / ,�� DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE omestic/Private Irrigation/Agricultural Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner: TYPE OF WORK New Well ❑ Replacement Well Water System Name Contact Name or Phone Number ❑ Well Alteration/Modification ❑ Other Monitoring Well(s) # of wells :; Soil Boring(s) # of borings Geotechnical # of borings Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair New PumpPump Replacement ❑ Pump Repair El Raise Well Casino Drilling Method __ Mud Rotary 71 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 ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft 7 Neat Cement (94 Ib bag/5-10 gal wafer) Sand Cement Bentonite (20% solids) Other sack mixl7 gal water Grout Placement Method Pumped _ Free Fall D Other Retardant / Accelerator (name) PEDESTAL Installed By Driller ❑ Pump Contractor -: Concrete Pedestal ❑Dimensions: Width_ in Christy Box ❑ Stove Pine Other ft Length ft Thick g_m submersible ❑ Turbine ❑ Other HP I 1 Pum Set P 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. _NIININII Al 24 1101_'R ADN-ANCL NO1 IC'1: REQ], IRI:D FOR INSPECTIONS - PLEASE CALL (2wj) 953-7697 DEPARTMENT USE ONLY Application Accepted By Z-- [. Date %� ;,7. Area L I �� Employee ID# Fr': 11 Grout Inspection By A Pump Inspection By I Date SPECIAL Well Permit --- Date WAIVER Received Soil Boring Inspection By Date COMMENTS All c/00 PE SC Received Amount Codes Info B Cash Remitted Dat r ;r I a Constructed Well Depth # I Invoice/1/,, bV�i%ID# TN EHD043-06 04/07!2022 Page I ort Well / Pump Permit It D a M N 41