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1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT ( � CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YE/A�RR FROM DATE �/ISSUED JOB ADDRESS /1� Z07-2-di e. N C'f 1l't 9 1 p o o/p 2 �s,w�] CrrY/ZIP/Tt�i�. ,7�3 44- `!7�/ m CROSS STREET,r 9,L1_ 0 Ra APN�,j�y�`v o 7'��ARCEL SIZEd2 LAND US`EE 2APPUCATTIIONN#Q a OWNER NAME �/#✓�AJ `,� TTLEe SA • AENor-JeSO� /y�PHONELY'�)q`�`� ` r'�O�� y OWNER ADDRESS i 3 /VybNO I CI Y/STATEMP&,I&I-c41i Nr -fS-6 97-Q"f CONTRACTOR Ii�NE P1t./� �NS /N C• PHONE (e?04) S 32— 11-3 G CONTRACTOR ADDRESS ��✓� 7y�.S e' ' CrrY/STATE2IP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZZip / LICENSE C-57 11C-61 ii /D-09 ❑ Other NUMBER g3S7V EXPIRATION DATE 7/�//Z02IiF � DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(439 1)0 Dibromochloropropane(4392)O 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 0 Other ❑ Monitoring Weil(s) #of wells C Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well 7 Out-Of-Service Well Renewal 0 Cross-Connection Repair ❑ New Pump ❑ Pump Replacement C Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION601) A Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool G Push Point ii Other - F Mit' /QD Proposed Well Depth 400 ft Excavation ;ZD in diameter 0 Open Bottom XGravel Pack/Gravel Size $2em- in diameter 2'Conductor Casing— g of in diameter / Conductor Casing Depth 6D' ft Well Casing Diameter d Z in Thickness/Gauge/ASTM Sched 6O 1: ❑ Steel APlastic ❑ Stainless Steel ❑ Other Grout Seal Depth go o ft 0 Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mud7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method A Pumped ❑ Free Fall 0 Other 0 Retardant/Accelerator(name) PAY N11-M PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other [7ITrFIVF ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick �in ❑ Christy Box 0 Stove Pipe PUMP 0 Submersible0 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 t4tJ :, Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells,1ftiiVt1dres, 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 HOUR ADVANCE NOTICE REQUTRF.D FOR INSPECTIONS-PLEASE CALL(209)953-7697 // DEPARTMENT USE ONLY Application Accepted By �`-� Date r Dd cL Area Employee ID# Grout Inspection By sg ey Date /-3- 2023 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS 1_A0 L-•►iVQ_ Or,- 7, r,7 77670 , - 1zl /2-`I70 PE SC Received Check#/ Amount Permit/ Codes Info Ely s emitted 'Da Service Re uest# Invoke# Well ID# 3F�i v 'y b716112, W EHD043-06 1025202 ��Pagc I o� Pa mit /Pump Pmit 2,