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I WELL/PUMP PERMIT SM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 NON-REFUNDABLE PERMIT / GALL ZU9 953-7b97 FOR INSPECTIONS LAVIKLb 'I YEAR FROM DATE ISSUED JOB ADDRESS A� � �, w.>; S< /4 ,C, -,V0- y� CITY/ZIP � Gc'. G. y �f 5%, CROSS STREET 3. A-. A J r�// {� QAPN I,'i� - //l.© - LOGO -X0 PARCEL SIZE6"1.b �-�- LAND USE APPLICATION # AJ1A, OWNER NAME arn�ecz„ �/n.i!'' L -J.] /✓��sl ,, PHONE 6&2-,)92 - 3. oo OWNER ADDRESS /++ 1 bJ , / ,!Stc CITY/STATE/ZIP t7593-7 ADDRESS SUBCONTRACTOR �r�(v11OC.�%' K,0 QQ�ixpG�raa' SUBCONTRACTOR ADDRESS 1,050 ncCc S�Hc� LICENSE VC -57 ❑ C-61 ❑ D-09 ❑ Other P H 0 N E (Z421.? 416 rl ' CITY/STATE/ZIP 6—// , C/ `T ✓6 -l.2 /PHOONE lg16) 37.2 ��3q CITY/STATE/ZIP WoST -<,' tr.,:.�u, Ab . 64 q: 5 6 :56 1 NUMBER t'7d.d'7c)'c4 EXPIRATION DATE—LI/ --30/ -4 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings VGeotechnical 2 # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ;,AD ft Excavation C- `;" in diameter C 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 Stee�11�"i Grout Seal Depth 2,o ft VNeat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement � c�j Y�i(7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall (/Other (D F: Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick SAN irmot nN COUNTY in ❑ Christy Box ❑ Stove Pipe FNVIRONMENTAL PUMP ❑ Submersible❑ Turbine ❑ 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, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 ItOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Applicatii GrOI Pum Soil Borin COMMENTS PE SC Received Check#/ Amount ate Permit/ Invoice # Well ID# Codes Info B -,--,Cash Remitted Service Request # SD EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit m D D m m y