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C) WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS it 01Q) d. �,�zkor �/2 ,l M CITY/ZIP 01�- � M CROSS STREET C /w�,fJ✓S� t%(Ltl II N© V Vyw f fp�P CEI(SIZE LAND USE APPLICATION OWNER NAME f �R �p I''� Il% Sg 1"`� Ur-L �`�� PHONE 7/ ,`-� ` uCAi OWNER ADDRESS l / / CITY/STATE/ZIP 2 CONTRACTOR v A r�JLO �� S S JUt(�I� 1 PHONE»�J CONTRACTOR ADDRESS �0 7t� CITY/STATE/ZIP `zloo- (fie SUBCONTRACTOR L'tI cS J/t/j►e s PHONES 2-7-t-71.7-0 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE x5-57 ❑ C-61 ❑ D-09 ❑ Other NUMBERy7 7 J `' EXPIRATION DATE ('7—k 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: Water System Name Contact Name or Phone Number TYPE OF WORK Aew Well ❑ Replacement Well i_I Well Alteration/Modification Li Other # Ll Monitoring Well(s) #of wells LI Soil Boring #of borings s) a Geotechnical ��/Vc Lut-Of-Service Well =i Out-Of-Service Well Renewal 1i Cross-Connection Repair f C ew Pum ❑ Pum Replacement I] Pump Repair Ll Raise Well CasingU WELL CONSTRUCTION SAN UO Drilling Method I Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E AQCJ/ Proposed Well Depth ft Excavation _L_L in diameter I--] Open Bottom Y Gravel Pack/Gravel Size STN �1�Ir ❑ Conductor Casing in diameter / Conductor Casing Depth l` ft R"144 Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched 'L6 V Li Steel [�'lastic ❑ Stainless Steel ❑ Other Grout Seal Depth _ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /0—7 sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Methodye Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) PEDESTAL Installed By )4 Driller EJ Pump Contract ❑ Other 11 Concrete P destal!]Dimensions:Width ft Length 19 ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP 09 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USEb NLY Application Accepted By� �Z_ Date Area Employee ID# _ Grout Inspection By Date /Z-�Z- ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS Lo is Ekvk 6uJ- ,11 t-, CO`( ZD PE SC Received Chec Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# IL-80 O 07-e123 Wpma�44&o ,5 J Y lo1Z8(23 WpQn wAvaa 0 43a wt r 0 EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit