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DoSuSign Envelope ID:B09CDE2E-6B76-4AAB-80AD-57B845AEE061 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 2�/09� 9553-7697 FOR INSPECTIONS �EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �2 1 l Gl( P D"'��J V-C i 1 CITY/ZIP fn� t1� �5� LA CROSS STREET 1+ 1� S� APN ( Y/�PARCELSIZE� L'V! LAND USE APPLICATION# o //� p m OWNER NAME GOn?�1 p pL,�pl Ly(_i�7i 'C-{--PHONE a.��u\��/��aC-/o�►--fir OWNER ADDRESS o\,o"L1.��L / - t,^ CITY/STATE/ZIPV` �/)��1 0"""- `'�6k �(0 CONTRACTOR cfx( �`t Vl!l/� t V ` ( PHONE / o:"',"`��}f . OL Oq CONTRACTOR ADDRESS PC) �� kq� CITY/STATE/ZIP RiUW�k1b40 + Qr( P-�lQ) SUBCONTRACTOR �I PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP p LICENSE C-57 u C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE [ [ DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria(4391),XDibromochloropropane(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 ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) ¢of borings E. Geotechnical #of borings Out-Of-Service Well ❑ Out-Of-Service W-�; R,;,.. - Cross-Connection Repair j LJ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method X"MUd Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth-,2,1,00_ft Excavation in diameter ❑ Open Bottom ;K Gravel Pack/Gravel Size PMn ❑ Conductor Casing in diameter / Conductor Casing Depth- ft RECEIVED Well Casing Diameter In Thickness/Gauge/ASTM Sched a Steel `�Plastic a Stainless Steel a Other Grout Seal Depth _ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack;r 117tpa6 w L� ?Bentonite(20%solids) a Other Ul.I lJ L 0 Grout Placement Method umped ❑ Free Fall ["I Other ❑ Retardant/Accelerator(name) C,,,JIwf y PEDESTAL Installed By -_ Driller I I Pump Contractor ❑ Other T AL Concrete Pedestal❑Dimensions:Width ft Length ft Thick REAL I H DEPARTM.E NT �in J 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: CPS 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. NIIN LN1UNI 24 IIOt R AD` ANCE NO I F: Rh;QI IRED I.OR INSPECT IONS-I'I"t;:#St,('ALI.(209)953-7697 /N1 DEPARTMENT USE ONLY Application Accepted By r Date L`��2 Area �" ` 1, Employee ID# A—L- Grout Inspection By ate 6 Gj 1 0 `' .? I' SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring'-._- By_ Date Constructed Well gepth ft COMME TS Y 14• - 1-f-- - PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 10-2•23 EHD043-06 04/07/2022 Page I of 2 Well!Pump Permit