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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 EXPIE2ES 'I YEAR FROM DATE ISSUED JOB ADDRESS 0 a L I CITY/ZIP It m CROSS STREET t+" / G+ C APN Or S 1 k' PARCEL SIZE 15 LAND USE APPLICATION# O OWNER NAME l (A V'l n PHONE �� m m OWNER ADDRESS v r '-t/ CITY/STATE/ZIP CONTRACTOR I PHONE `+ C CONTRACTOR ADDRESS o e _ I�Y� CITY/STATE/ZIP ex SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CI STATE IP LICENSE C-57 11 C-61 ❑ D-09 ❑ Other NUMBER XPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring - 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 11 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal U Cross-Connection Repair ❑ New Pump J Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary _] Air Rotary Auger Ll Cable Tool a Push Point ::] Other Proposed Well Depth on ft Excavation L'all in diameter ❑ Open Bottom .Gravel Pack/Gravel Size in diameter I I Conduc Casing in diameter / Con uctor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sche (1- I] Steel Plastic I', Stainless Steel Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water entonite(20%solids) ❑ Other Grout Placement Method ^mped ❑ Free Fall ❑ Other u Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller n Pump Contractor P. Other [:] Concrete Pedestal ]Dimensions:Width ft Length ft Thick in I] Christy Box Stove Pipe PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level 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. MINIt11'i1 24 1101'R ADN.ALN(E NO TIC11 ImQulltl?1)I'(,m INSPIA I1O,%S- ri'l_,iSr 4'.i1.1. EP e TMENT USE ONL _ 7 U Application Accepted By . �i Date `T t Area ` L EPA Grout Inspection By t0 �s2>roc t1114 Date W14Z7 I ! SPECIAL We Pump Inspection By Date ❑ WAIVER Receive '•G� Soil Boring Inspection B Date Constructed Well Dept4 I.. ft COMMENTS I Y►^1 112 UZZ Per r 0+1*,j 2e; jO P,'r►m 1 ej rnt'rr f?rt'%� �r c,rn� 6' l . �r r°: G '7' 21 ss WN PE SC Received a Amount Date Permit/ Invoice# D# Codes I fo B Cash Remitted Service Request# .7'-0 ;. I 5_ N 34-1 EHD043-06 04/07/2022 `ram, � 1�j5 'C 1 -%,-k 1�4N Page I of 2 Wcll/Pump Permit -