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t ' f 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 NON-REFUNDABLE PERMIT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED � r JOB ADDRESS �. UDC� �.I t �/ YLl N �� Ij l ITY/ZIP L IPln C/� C}SL 3 m CROSS STREET u�� APN V6:T t oy PARCEL SIZE4(0 > LAND USE APPLICATION# O \/ X OWNER NAME V ' � de5 p /� '92 7/� `� J2 PHONEn�O%/'�/✓� ��J(p� �? OWNER ADDRESS p/ j T�I�/-�r�� ea CITY/STATE/ZIP l ulde ^ 6A g�L3l1i CONTRACTOR �� ►i )Q,�l✓G L��(✓I G'� �(�� PHONE-Rq 777 -2-7677 � CONTRACTOR ADDRESS "10 �.I/7� CITY/STATE/ZIP `/P(t SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �J LICENSE ?LC-57 ❑ C-61 ❑ D-09 0 Other NUMBER lel A)71_ EXPIRATION DATE Z/ DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)rr Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 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 ❑ Other s ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings s) 9 ❑ Geotechnical of borin s rth ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair WU 14, 90 2rNew Pum 0 Pum Replacement ❑ Pum Repair ❑ Raise Well Casing ` ✓ C ?3 WELL CONSTRUCTION yT RpNM C0UN Drilling Method (Mud Rotary ❑ Air Rotary El Auger 0 Cable Tool ❑ Push Point ❑ Other yDFP � ry AlAr Proposed Well Depth 3100 ft , Excavation / Z ��/ in diameter ❑ Open Bottom YGravel Pack/Gravel Size N?Tmeter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_j�e in Thickness/Gauge/ASTM Sched till ❑ Steel KPlastic ❑ Stainless Steel 0 Other Grout Seal Depth)r ft ❑ Neat Cement(94/b bagl5-10 gal water) fd Sand Cement /d•.3 sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By V Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick 1� in 0 Christy Box ❑ Stove Pipe PUMP 0 Submersible❑ Turbine ❑ Other HP S Pump Set_Z20g2__ft Standing Water Level — it 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USjE ONLY /-- Application Accepted By ` Date �-�l Z� Area p4 I " 1 Employee ID# /tT Grout Inspection By DateI?XF-Z,M ❑ SPECIAL Well Permit Pump Inspection By Date'7_—] .Tkxj,3 ZO Z`\ ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �i5 �6 L Z(o t- L�I�- Fa-c1A�T.2 ANP Lj -c0�0 PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info i3y Cas Remitt d Service Request# 812y123 WPOOL114186 v ciS _ a 812y1z3 WP�y4�g9 `s EHDO43-06 04/072022 Page 1 01`2 Well/Pump Permit