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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT �y�CALL 209)953-Z697 FOR INSPECTIONS, EXPIR,E�S 'I /YEARR FROM DATE ISSUED <br /> IoBADDRESS -7 �JZ/7��� �`' Iv /CIT / IP 7/i. 1 I �� m <br /> CROSS STREET [=L�� APN / !/K/ ^-Z_36ARCEL SIZE 6 4: LAND USE APPLICATION# <br /> L� <br /> OWNER NAME A �/!'I 0/17 GGI / C m <br /> / {�� PHONE Cn <br /> OWNER ADDRESS , L�/1 P"' ,I:I:r n CITY/STATE/ZIP <br /> CONTRACTOR /t (%i �� aL�,I�(1��,W PH/ONNEE S 3 7�p <br /> - Y 7� <br /> CONTRACTOR ADDRESS f �Cf CITY/STATE/ZIP ' Oo rp/4 <br /> SUBCONTRACTOR /V o 13 /r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,,�C-57 ❑ C-61 ❑ D-09 [IOther NUMBER 37;7j or EXPIRATION DATE (O` <br /> DOMESTIC WELL SAMPLING:JVGeneral Mineral/Coliform Bacteria(4391);Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ,Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )ff New Well ,*Replacement Well ❑ Well Alteration/Modification 0 Other <br /> s <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings s ❑ Geotechnical borings <br /> 'd1 f borin <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Y4f�NT <br /> ew Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingI� <br /> WELL CONSTRUCTION d✓ M o <br /> Drilling Metho dRotary g AR °t�❑�Mud Rot ❑ Air Rota ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 ft Excavation in diameter ❑ Open Bottom eGravel Pack/Gravel i deter <br /> ❑ Conducto asmg in diameter / Conductor Casing Depth ft H ENVjRv DNUNCOUN <br /> Well Casing Diameter_-in Thickness/Gauge/ASTM Sched ' nD ❑ Steel Plastic ❑ Stainl ss Steel �, F 7y <br /> Grout Seal Depth 100 ft ❑ Neat Cement(94 lb bag/5-10 gal water) XSand Cement 7 sack eater <br /> 0 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 0 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> lin 0 Christy Box 0 Stove Pipe <br /> PUMP ,eSubmersible❑ Turbine ❑ Other HP T_ Pump Set ft Standing Water Level ft <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT SE NCL�Y q Jif <br /> fi <br /> Application Accepted B Date '5 /_ Area ` Employee ID# 'y <br /> Grout Inspection By r Date (.rrZcy� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �� \ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ;Ih6krs VzAw/ -IaA al Ade-eel r-�r do h/uS ,S/io vc <br /> 7i7 & At, /0 <br /> PE SC Received Che Amount Permit]Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> y37 Zo 512912-14 53� <br /> Y 9/ /goo <br /> ERD043-06 04/07/2022 Page I of 2 Well/Pump Permit <br />