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N 1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT PERMIT CA.}L�L(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ( 0 1 l �� '�C7��`` 1 `�" CITY/ZIP _ Lo ', m CROSS STREETIlr �rl� �Cl APN �� ` IJ/Ci PARCEL SIZE :7. LAND USE APPLICATION# o ter- M i m OWNER NAME /' (� ,\� \ �' { PHONE /' !,/�� y OWNER ADDRESS �, �- t�yC'L`\C� c CITY/STATE/ZIP �L-� `�\ ' 15�'''lV CONTRACTOR a �G"- ( ` PHONE Tg^ d /y� '-V l) 1-1, CONTRACTOR ADDRESS � - GW V CITY/STATE/ZIP ��Uli W,, `'A 619M SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE L4 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER loeTal EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other 0 Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair *New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad 0 Steel ❑ Plastic 0 Stainless Steel 0 Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water 0 Bentonite(20%solids) 0 Other Grout Placement Method ❑ Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) PEDESTAL Installed By 0 Driller a Pump Contractor 0 Other ❑ Concrete Pedestal ❑Dimensions:Width�_ft Length ft Thick 4A in ❑ Christy Box 0 Stove Pipe PUMP R Submersible0 Turbine 0 Other HP 17 Pump Set_2J&L_ft Standing Water Level 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �� `�DEPARTMENT USE nNLY lqq Application Accepted By V" Date `O2_LtArea � EmpkD Grout Inspection By Date ❑ SPECIAL Well PIV itt;. 's Pump Inspection By Date ❑ WAIVER Received �� 67 Soil Boring Inspection By Date Constructed Well Depth -�q 2nn, ft COMMENTS SAki — EN M COIJ PE Sc Received Check#/ Amount Permit/ _Codes Info By Cash Remitted Date Service Request# Invoice# �Ibl' �+ 8 •9• 4 4 EHD043-06 04/07/2022 • (�' f�O� A P 1 of 2 Well/Pump Permit