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a <br /> WC11-1_/1-vtrilr rGrxrnn v <br /> WM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N <br /> ` nL��I �-� 9 <br /> 1R 5G�3 m <br /> JOB ADDRESS D��l C11 ' CITYILP D <br /> CROSS STREET ' I 't'` 7 T� '/�-7. _APN QC-7- 1I L A-7 PARCEL SIZE `'Of LAND USE APPLICATION# A <br /> �J �J �',j r m <br /> Q n tr t PHONE r�(v I � � � - S�-1 Ki Y? <br /> OWNER NAME 1\L\t ( f 1 ^ `- <br /> OWNER ADDRESS I `TCGknS <br /> 1331 S • V- , son, W�\Y CITYISTATE21P �' � 1�� <br /> �J <br /> CONTRACTOR n ' 1 n PHONE �?u� ?(C9� -,; 7 " 9 <br /> Z CITY/STATEIZIP ;�,l �, CA 1 YJ <br /> CONTRACTOR ADDRESS <br /> PHONE <br /> SUBCONTRACTOR <br /> CITY/STATEIZJP <br /> SUBCONTRACTOR ADDRESS <br /> LICENSE 'AC-57it C-61 L7 D-09 7 Other <br /> NUMBER ExPIRATION DATE -31 - a <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private "1 Irrigation/Agricultural -1 Industrial ❑ Water Quality Monitoring 1 Soil Sampling/Characterization <br /> ^, Public Water System Contact Name or Phone Number <br /> If different from Owner: Water System Name <br /> TYPE OP WORK ,New Well 7 Replacement Well Well Alteration/Modfication Other #of bon <br /> 7 Monitoring Well(s) #of wells Soil Boring(s) <br /> #of borings Geotechnical <br /> 2 Out-Of-Service Well Out-Of-Service Well Renewal - Cross-Connection Repair JUN <br /> New Pum Pum Replacement Pum Repair Raise Well Casing ��AQ <br /> UIN �Lg <br /> C <br /> rWELLONSTRUCTION NTY <br /> Method Mud Rota , Air Rotary Auger Cable Tool 1 Push Point OtherTY <br /> ed Well Depth b ft Excavation in diameter Open Bottom Grftvel Pack/Gravel Size t i ANT <br /> 7 Conductor Casing in diameter / Conductor Casing DepthG(� Steel Plastic - Stainless Steel .1 OtherCasing Diameter in Thickness/Gauge/ASTM Schad(l ' sack mix/7 al water <br /> Grout Seal Depth �c_ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement g <br /> -1 Bentonite(20%solids) i i Other <br /> Grout Placement Method Pumped i) Free Fall 1 Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller i Pump Contractor Other <br /> Concrete Pedestal:-!Dimensions:Width � ft Length_ _it Thick <br /> in -' Christy Box Stove Pipe <br /> PUMP �Submerslble� Turbine � Other HP � _ Pump Set ft Standing Water Level��ft <br /> Plot Plan Requirements: Attach a plot plan with the exact locahon of water well with respect to the following Items GPS <br /> ctures, <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, stru <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br /> Agriculture,industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> �ii�i�ii'�l_-liivi.i<:u�� �a_i_A�;�,th.n4.lni+<F ;in: I •ii , iii,'•, '- <br /> D P RTMENT USE ONLYp_ ,� <br /> Application Accepted By <br /> Date 3 �ZZ Area Employee ID# <br /> Grout Inspection By r Date � 4— PSECIWell Permit <br /> Pump Inspection By <br /> Date �Z ~ WAIVER Received <br /> Soil Boring Inspection By <br /> Date 2�7 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash RemittedService Re uest# <br /> 20 4 3' <br /> SZ 433& <br /> l� 4.3 <br /> p 3 <br /> 2 <br /> Well I Pump Penni, <br /> EII0043-06 04/07/2022 Page 1 of 2 <br /> &W 4 /ofs-'s E`3 S <br />