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1, E-MAILED 1 WELL/PUMP PERMIT .� y�5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTONAVENUE-STOCKTON CA 95205 -(209)4683420 NON-REFUNDABLE/PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �-G CITY2IP m CROSS STREETyTfICAL TDN� ' APN 099' 3-D7o'3�j0-4 CEL SIZE'3'SG' LAND USE APPLICATION# o T / ! t� X OWNER NAME ✓,4e K �AENA+f S A*.v L/i`/ %/ZfsS� PHONE `�'�4�`'�'Z` / ?� m OWNER ADDRESS //V V1 E• 6rA-7-& H-r I X0 CITY/STATEIZIP /'27"0 Off"✓ La) 9 310-,97,9 J CONTRACTOR 0-4-av*f?4 ') ^"f �N �' PHONE 1 / S�32-413,4 0 CONTRACTOR ADDRESS 0'43 f`f Lv c-4 r_*— Cr-' CITY/STATEIZIP _.J� 'e;q i x370 SUBCONTRACTOR ' PHONE SUBCONTRACTOR ADDRESS ,Cr Y/STAT.EIMPP c IA LICENSE AC-57 0,C-61 ❑:D-09 ❑_Other NUMBER"7 lis 7 7 EXPIRATION DATE ? 3� �+D, DOMESTIC WELL SAMPLING--y,,General Mineral/Coliform Bacteria(4391)aDibromochloropropane(4392)C':"Arsenic(4393) y INTENDED USE Domestic/Pdvate EjIrigation/Agricultural ❑.Industrial d Water Quality Monitoring (7';$oil Sampling/Characterization 0 Public Water System (Y If different from Owner. Water System Name Contact Name or Phone Number Q TYPE OF WORK ew Well XReplacement Well D,Well Alteration/Modification AOtherAX• y &,v 4/RigIA10-r #of borings #of borings D<Monitoring Weil(s) #of wells El Soil Boring(s) WGeotechnical ff`Out-Of-Service Well ❑'Out-Of-Service Well Renewal D'Cross-Connection Repair ❑ New Pum 0'Pump Replacement D.:Pump Repair OnRaise Well Casing WELL CONSTRUCTION Drilling Method/;Mud Rotary O-Air Rotary ❑:•Auger ❑ Cable Tool ❑'Push Point 0. Other �. Proposed Well Depth ob it Excavation IA" in diameter ❑'Open Bottom 19,,Gravel Pack/Gravel Size. in diameter A Conductor Casing O in diameter / Conductor Casing Depth O ft A Well Casing .Diameter�in Thickness/Gauge/ASTM Sched OSteel pPlastic ❑''Stainless Steel ❑:Other f Grout Seal Depth .SCD' ft D;;Neat Cement(94 Ib bag/5-10 gal water) b Sand Cement sack ;7. a ND Bentonite(20%solids) 9#Other �Grout Placement Method j$Pumped ❑=Free Fall d.9ther ❑;Retardant/Accelerator(name) PEDESTAL Installed By C.Driller a Pump Contractor �::; Other 3d�• 1JO'Concrete Pedestal❑Dimensions:Width ft Length ft Thickin Q:ChristyBox 0 ; Stove PipeUMP ❑SubmersibleD Turbine q:-Other HP Pump Set ft Standing WaterPlot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following it 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 MIINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USE ONLY Application Accepted By ,/V/lb6� Date s-r�- Area Employee ID# / L Grout Inspection By :27, 7� --s--- Date_ /ZS Q. SPECIAL Well Permit Pump Inspection By Date ❑;`;\WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS A0 Ort yp. PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Cash Remitted Service Request# 74' - 34/ /709V EHD043-06 04/072022 Z Page t of 2 Well/Pump Permit -2-0 17 l7 od