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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 CALL 209) 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> �srQ/on �� 9334 m <br /> JOB ADDRESS L&MY, A'ye CITY/ZIP . <br /> ,7_ m <br /> CROSS STREET c.t elr� 4114e APN �y�� /'DPARCEL SIZE Oi <br /> 51 LAND USE APPLICATION# o <br /> OWNER NAME ? /GAY/1{!� l���M PHONE(,-7e ZaZ m <br /> OWNER ADDRESS GB�7 Zy `mac/'ry n (��G CITY/STATE/ZIP �,S �h (/'�' ?'S 3!l0 <br /> CONTRACTOR lea, �LL/G�//I� J//.7L f PHONE 7w 9 77Z` Z �j 7 7 <br /> CONTRACTOR ADDRESS OD �QII�/i w�/�n �/� CITY/STATE/ZIP//',4 S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> � G <br /> LICENSEC-57 11C-61 ❑ D-09 LI Other NUMBER IDS/077J EXPIRATION DATE U 3� ZOZ'y <br /> DOMESTIC WELL SAMPLING:)(General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private i_I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characte�Il��``1I 1P <br /> F1 Public Water System �� TT•r/ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well A Replacement Well ❑ Well Alteration/Modification ❑ Other Ad4 i, <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical of 4462023 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair AQUIN C <br /> New Pum i Pum Replacement ❑ Pum Repair ❑ Raise Well CasingV1R DU <br /> WELL CONSTRUCTION rl bt;P AL <br /> Drilling Method )eMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other "New <br /> Proposed Well Depth 3010 ft Excavation /Z//,Vin diameter ❑ Open Bottom )(Gravel Pack/Gravel Size 15 in diameter <br /> C' Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1Q in Thickness/Gauge/ASTM Schad S_/7221 r_1 Steel 9plastic Cl Stainless Steel ❑ Other <br /> Grout Seal Depth 44W ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement �d •3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed ByLoDriller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width_(—ft Length J6 ft Thick G <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 11 Other HP 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 U7S ;-771 LY <br /> Application Accepted Date Area -457/t7!? Employee ID# <br /> Grout Inspection By r Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �i Date Z ❑ WAIVER Received <br /> Soil Boring InspectionBy Date Constructed Well Depth ft <br /> '9/wCOMMENTS �w/,R 'o-eLO/'W <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> 1137,e i80 :2- ZD h-f/zs WP ss© <br /> 3 9/ .2- ss <br /> 3RD OS/ 2 <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />