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r�• ell � � 6-� <br /> ' I WELL/PUMP PERMIT <br /> SAN 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 <br /> �1�}YEAR <br /> /FROM DATE ISSUED <br /> JOB ADDRESS /l Z�b Al &/4 CtIkG CITY/ZIP m <br /> h?d,45,_ aLI CQ- <br /> CROSS STREET LAPN OJ"/ ��'[/(O'/ PARCEL SIZE � LAND USE APPLICATI/O,N/J# <br /> OWNER NAME y)ri r T 2 PHONE �Q1/7`Q3- 53 9 P <br /> OWNER ADDRESS A j 2152 1R�R1rQ Cr-c de (L 12.G' CITY/STATE/ZIP Loc// Lt� CGISLyU <br /> CONTRACTOR �3 Mr t'(t';A rq L PHONE `�/ 777i' 2 S 7+ <br /> CONTRACTOR ADDRESS S/j� �(/lj//-y7 I: CITY/STATE/ZIP 4!�14�VV Jaj/!/!2! el' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 701 71)7,0 EXPIRATION DATE 457 3/ ZOZ Z <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number !7A YAW-A <br /> TYPE OF WORK [XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Borings) #of borings ❑ Geotechnical {/#of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing Aly c` <br /> WELL CONSTRUCTION E�/ //�C <br /> Drilling Method Y Mud Rotary ❑ Air Rotary El Auger ❑ Cable Tool EI Push Point ❑ Other N THD NMEN7A N>Y <br /> Proposed Well Depth Sao ft Excavation in diameter ❑ Open Bottom irGravel Pack/Gravel Size I 'At)reter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Y&Iin Thickness/Gauge/ASTM Sched Q.2/ ❑ Steel )(Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement /B •3 sack mix/7 gal water <br /> ❑ Bentonite 0%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By OyDnller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pddestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set__Z ea ft Standing Water Level <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <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 /> INIINiMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date d] a Area Employee ID# Firtiwk <br /> 67 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �s��s� Date � Lz/Z y ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Well 14 b h/e� ib w o'le'- <br /> PE SC Received Che Amount Permit/ <br /> Codes Info By ash Rem!tt d Date Service Request# Invoice# Well ID# <br /> age �s a 152­7 sl; 5 <br /> U.C. tAlpA <br /> q;10 <br /> 3 I I ss <br /> 439; 7 <br /> 3 a <br /> EHD043-0G 10/25/2021 Page I ort Well/Pump Permit <br />