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1 WELL/PUMP PERMIT
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - STOCKTON CA 95205 - (209) 468-3420
<br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED
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<br />JOB ADDRESS 31 ) I 1111 tic. t...),tib lb — il E" r - a-rya'', Skeit4-b-7 i eh 526 ,2
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<br />CROSS STREET "A#4... Platme) APN / 33'- cm" o --/ ok. PARCEL SIZE dae, Ad- LAND USE APPLICATION #
<br />OWNER NAME ....5;./ if elf‘, in Areea Fea,c) Conicetil Aece149' PHONE AP 9 57 - 883
<br />OWNER ADDRESS 2i. Z.- (4...)/a7eie Al . 77.115/ CITY/STATE/ZIP j';'6 Ce/40-21 61 '52't
<br />CONTRACTOR Gm -zit 14.),Ocri(44-6e... 25 c Peeitrei,— kr Cd-A--7 PHONE 7/‘ 7?", - filiqCii
<br />CONTRACTOR ADDRESS 7c- POOLA MS t fri .5 ,Sf7.-e-et CITY/STATE/ZIP 121)(4// C-." ? 5.6 AZ i
<br />SUBCONTRACTOR PHONE
<br />SUBCONTRACTOR ADDRESS Curt/STATE/ZIP
<br />tia-57 7 542 4 7 0 771,Vre-C,ZZ LICENSE H C-61 ll D-09 FI Other NUMBER EXPIRATION DATE
<br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393)
<br />INTENDED USE Li Domestic/Private LI Irrigation/Agricultural u Industrial U Water Quality Monitoring XSoil Sampling/Characterization
<br />H Public Water System
<br />If different from Owner: Water System Name Contact Name or Phone Number
<br />TYPE OF WORK Li New Well Li Replacement Well n Well Alteration/Modification U Other
<br />H Monitoring Well(s) # of wells Li Soil Boring(s) # of borings XGeotechnical 7 # of borings
<br />H Out-Of-Service Well LI Out-Of-Service Well Renewal Li Cross-Connection Repair P4 " , New Pump Pump Replacement Pump Repair 7 Raise Well Casing
<br />4 ei°&of WELL CONSTRUCTION
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<br />Drilling Method Li Mud RotaN ii, FI Air Rotary Auger U Cable Tool )Push Point r Other
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<br />t. ,L. - Proposed Well Depth (F, -.-) ft Excavation in diameter n Open Bottom 11 Gravel Pack/Gravel Size --Frtldiapheter
<br />U Conductor Casing in diameter / Conductor Casing Depth ft SA A , .9 4',
<br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Li Steel I I Plastic n Stainless Steel Li Otq9 C Q
<br />Grout Seal Depth at, ft gfi Neat Cement (94 lb bag/5-10 gal water) 1 Sand Cement s g
<br />F. Bentonite (20% solids) LI Other
<br />Grout Placement Method iG Pumped H Free Fall I . Other n Retardant / Accelerator (name)
<br />PEDESTAL Installed By L Driller I I Pump Contractor IT Other
<br />U Concrete Pedestal [:Dimensions: Width ft Length ft Thick
<br />in U Christy Box I I Stove Pipe
<br />PUMP Fl Submersible El Turbine n Other HP Pump Set ft Standing Water Level ft
<br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS
<br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures,
<br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic,
<br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well.
<br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697
<br />DEPARTMENT USE ONLY
<br />, . . i < —....--17--72- / Application Accepted By - --- L_____ Date 1/ i ,"7/ Area 0-0(: Li.° V
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<br />I Employee ID# I l'i ) -2
<br />Grout Inspection By Date 0 SPECIAL Well Permit
<br />Pump Inspection By Date 0 WAIVER Received
<br />Soil Boring Inspection By 7iAs-si 71 Date T/1, L/I, L Constructed Well Depth ft
<br />COMMENTS &;+ T A 4.5; -v., ,!..1( i 0 Nil fert11,-'W- . -
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<br />Remitted Date 1 r
<br />Permit/
<br />Service Recluest # Invoice # Well ID# -Cash
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<br />EHD043-06 10/25/2021
<br />Peg 1 of Well / Pump Permit
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