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r 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT /� / CALL /209 953-76997�FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS —1 '5 2 5LL__R- 2E&)6�1 ( p Icy/ -802k2a Cl- q53� m j �P G� CITY/ZIP_ CROSS STREET / d� �d _AP ao 3 / 1' q(� p n ^ L PARCEL SIZE LAND USE APPLICATION# p OWNER NAME .�/�lL(�I/,l A)P IJ0 1 ;0 / C PHONEJ,:�> '� 7/-�/ '9QV 7 N OWNER ADDRESS 7/de "eel CITY/STATE/ZIP 4eo/;7 C,a c CONTRACTOR r In 7�� //7 1.,76 PHONE CONTRACTOR ADDRESS �32e7 CITY/STATE/ZIP //�Ijs SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/Z I P LICENSE C-57 C', C-61 D-09 E Other NUMBER /1,�/7U7U EXPIRATION DATE / Q DOMESTIC WELL SAMPLING. eneral Mineral/Coliform Bacteria (4391) ibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ^Domestic/Private - Irrigation/Agricultural 7 Industrial 11 Water Quality Monitoring F Soil Sampling/Characterization C Public Water System Ifdifferent from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK A New Well Replacement Well Well Alteration/Modification ❑ Other Monitoring Well(s) #of wells Soil Boring(s) 4 of borings Geotechnical #of borings Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair New Pump G Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ,/Mud Rotary Air Rotary , Auger 7 Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 30,✓ ft Excavation I2 i/ in diameter Open Bottom 3 Gravel PacklGravel Size in diameter Conductor Casing in diameter / onductor Casing Depth ft r Well Casing Diameter in Thickness/Gauge/ASTM Sched!�U2 z f 11 Steel (Plastic 7 Stainless Steel -1 Other Grout Seal Depth ,2,Q� ft ❑ Neat Cement(94lb bag/5-10 gal water) 4sand Cement Ild-3 sack mix/7 gal water - Bentonite(20%solids) ❑ Other Grout Placement Method Pumped :1 Free Fall E Other :i Retardant/Accelerator(name) PEDESTAL Installed By V Driller Pump Contractor D Other Concrete P destal -Dimensions:Width_ ft Length ft Thick /a in L Christy Box ❑ Stove Pipe PUMP Submersibles Turbine ❑ Other HP Pump Set /cgCJ ft Standing Water Level ft Plot Plan Requirementst 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. 111i\IlIUII 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USE ONLY Application Accepted ByA Date I)A Area V4 Employee ID# (` Grout Inspection By Date �� ❑ SPECIAL Well Permit Pump Inspection By �� - Date f 141 2/. ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS I 6r-0 f ) ! Ca-ld Lli3O I - 9,ISQ4 1 —12A k\__�S(QA - 6 PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice C *?D# ►� s as iti �. �q J ., ' o 0vi R k r LHD043-06 10252021 Page I of 2 Well/Pumo Permit