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F r 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 19-53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS l.:-L `)11L, t C %- -t- �\ L�- CITY/ZIP CROSS STREET T CAC,k l"L'•1 t-_ I7 APIN 0 1 0 330 PARCEL SIZE `�"i.' ` LAND USE APPLICATION# A � -T(\ ` m OWNER NAME --c1 C, K -T(\ , 1 C.' ( \ ,PHONEClr i -�;� — CJ 51C"� y OWNER ADDRESS I W � 1 ff ( u I� 1 f` �� CITYISTATEIZIP ACLL 't, �(,'- ( A � ci SX, CONTRACTOR ��4 l i '{ S r I PHONE J(, `l J 4 - -7J`7,�7t CONTRACTOR ADDRESS CITY/STATE/ZIPC'.6� A �� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ) C-57 l C-61 ❑ D-09 ❑ Other NUMBER-2M(.3 3 EXPIRATION DATE —7- DOMESTIC WELL SAMPLING:%General Mineral/Coliform Bacteria(4391)14 Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE _!.Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization } El Public Water System R�� It different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK $,New Well ❑ Replacement Well 11 Well Alteration/Modification ❑ Other o ❑ Monitoring Well(s) #of wells U Soil Bonng(s) #of borings ❑ Geotechnical #or borings y ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair ISA N,JO �OZ2 New Pum ❑ Pum Replacement 13 Pump Repair 11 Raise Well CasingFN V/AQP/N WELL CONSTRUCTION N 6FY T�Nry Drilling Method 'bk Mud Rotary ❑Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other A T MENT Proposed Well Depth ':i ft Excavation ; in diameter ❑ Open Bottom D Gravel Pack/Gravel Sized—in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Ci ❑ Steel S1 Plastic ❑ Stainless Steel 0 Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal wafer) E Sand Cement sack mW7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method FkPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ,Ei Driller ❑ Pump Contractor , ❑ Other Concrete Pedestal❑Dlmenslons:Width - ft Length �" ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP V Submersible❑ Turbine ❑ Other HP `) Pump Set "I-,' ft Standing Water Level i -- ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS 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. ,11A01i ll ;-1 Iltli k ilr\ \t L NO R.L.14.01,IRUD i Ok I\SPL('I IONS-I'LF.A,•i_i ti 1 (209 1)' DEPARTMENT USE ONLY t { Application Accepted By �� Date r �'`1 Area �C Employee ID# � ? !'_ Grout Inspection By Date 1 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info C sh Remitted Service Re uest# _; = V" u1 ; P �3�tI .50 1Poi 33V4a 470 EHDO43-06 10/25/2021 Page 1 ort Well/Pump Perm