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DocuSigfl Envelope ID:6E1 EC6BA-6205-46D9-BCCB-8448F9459603 e 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 I YEAR /FROM DATE ISSUED G JOB ADDRESS n-r� � Cr'� CITY/ZIP m CROSS STREET (,� /�M `�" APN V �y� �j` PARCEL SIZE `��rLAND USE APPLICATION# O OWNER NAME t��Yn C� ( 1 IS��/ 4, -1 t� �jO Ir � PHONE 209298�/3�069 N OWNER ADDRESS �✓v��(n ��-vr 1 } CITY/STATE/ZIP 1 1 l/LV cif i C* �v ✓� CONTRACTOR �'��"� ' 1 �t V r PHONE Q!_A_,)0No�K/�,0l DL4 CONTRACTOR ADDRESS i�� G�-U IO �t l� p� 4�44LI /� CITY/STATE/ZIP I�It f V W -( SUBCONTRACTOR JAI k/ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE IKDomestictPrivate ❑ Irrigation/Agricultural Industrial C 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 U Other ❑ Monitoring Well(s) #of wells Cl Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal U Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary Air Rotary Auger a Cable Tool ❑ Push Point ❑ Other Proposed Well Depth- e')I obft Excavation in diameter ❑ Open Bottom /f9Gravel Pack/Gravel Size in diameter ❑ Conduct r Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 4Z 21 ❑ Steel A Plastic Stainless Steel XME� Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement i;umMMOvater �entonite(20%solids) CI Other Grout Placement Method umped Ci Free Fall Other I7 Retardant/Accelerator(name) PEDESTAL Installed By CI Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Ci Dimensions:Width ft Length ft Thick SAN JO in ❑ Christy Box Li Stove Pipe EN 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. i SII �Ii11 NI 24 110t HAD% Ea£ I No I R F f L(A 111H)I1318 I\ai'L( I10%,"-V[ 1.V'4 ( _k1.I_F260) DEPARTMENT USE ONLY Application Accepted By Date Z l 7 Area—& Employee ID# Grout Inspection By Date Z i i SPECIAL Well Permit Pump Inspection By Date L WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS � L 1 u4 A �r:,.��- ei r .c.GT PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info gyl Cash Remitted Service Request# 3 � EHD043-0604/07/2022 Page I oft Well;Pump Permit