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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 1 YEAR FROM DATE ISSUED JOB ADDRESS .? tg Trc-�-hz U-,NJ 1Z 17 CITY/Zip A u1�1'c : q S."17C m c,n� iZ ► APN 00730-2 l �s J n CROSS STREET / ' PARCEL SIZE d —t • LAND USE APPLICATION# p OWNER NAME NAME �q f 9 y PHONE OWNER ADDRESS ►�. UZ `w CITY/STATERIP LUd11 (a� yo CONTRACTOR t� I`\ 1� -" ( PHONE ",7�-ItI 3( -i CONTRACTOR ADDRESS 1- C 1;L J� `'"f Lx CITY/STATE/LP V 1� C-A (I S CS 'l SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �yttc�7 S 7 LICENSE -A C-57 F1 C-61 ❑ D-09 0 Other NUMBER I 1 7 3 EXPIRATION DATE / I DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) : Dibromochloropropane(4392) - Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterizati }/ 1 Public Water System RAll If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK A New Well ❑ Replacement Well C Well AlterationlModification !I Other D ❑ Monitoring Well(s) #of wells C Soil Boring(s) #of borings D Geotechnical #0 b gS q 81. C Out-Of-Service Well ❑ Out-0f-Service Well Renewal ` Cross-Connection Repair�� /0 2O[ *A New Pum ❑ Pum Replacement C Pum Repair Raise Well CasingENV/q QUIN WELL CONSTRUCTION H 0Ep FlyTq Ty Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point I Other ARTM T Proposed Well Depth .%Q ft Excavation 1-2 in diameter D Open Bottom Gravel Pack/Gravel Size 1/4 - in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter C, in Thickness/Gauge/ASTM Sched C-I.X0 fl Steel %Plastic i7 Stainless Steel 1 Other Grout Seal Depth I CC ft C Neat Cement(94 Ib bag/5-10 gal water) --,C Sand Cement )C.3 sack mix17 gal water ❑ Bentonite(20%solids) C, Other Grout Placement Method;PSS Pumped C Free Fall D Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By NDriller _1 Pump Contractor ❑ Other )I.Concrete Pedestal CDimensions:Width I ft Length 3 ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ,YY Submersible?Turbine n Other HP__ Pump Set &L ft Standing Water Level t SJ 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. DEPARTMENT USE 2NLY Application Accepted By L Date /s a $ z Area 1 / Employee ID# EIZ Grout Inspection By Date -Lb ❑ SPECIAL Well Permit Pump Inspection By rr Date (o SIA O-Lo`Z-J 0 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth n COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cas Remitted Service Request# g3Bv 0571 IS-6 ,1a-8-aa L1366 SO 4 y8b t q 435) 4155' 4 43ga 4 76 0 L'.HIJIM)-06 04/07/2022 Page I or2 Well/Pump Penut