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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENJE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMITCALL <br /> _-_/'IC-A/LL(209)953-7697 FOR INSPECTIONS �E/X�P,IRES 1 YEAR <br /> FROM DATE ISSUED <br /> 1 59 <br /> JOB ADDRESS �Z 5, ��LYX/, /dCj�i /�// CITY/ZIP /7Zei�I � v/r �5 ZZO m <br /> CROSS STREET /(,,9[3,�rI�OG.-J�f0 XW/ AP Z30' -OSPARCEL SIZE 4/ LAND USE APPLICATION# A <br /> y <br /> OWNER NAME 16¢�/fid l��/// �JA � / PHONE <br /> OWNER ADDRESS !Zy� /U /%/!it� /%/�wi/�!f.G l?!/ CITY/STATE/ZIP <br /> CONTRACTOR PHONE Lam// 77Z 2-7 5-7 <br /> CONTRACTOR ADDRESS � 61X /3.7-Y CITY/STATE/ZIP/*&,,A., <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE KC-57 G C-61 ❑ D-09 ❑ Other NUMBER a 7D 79 EXPIRATION DATE X/- 70 zz <br /> DOMESTIC WELL SAMPLING:b(General Mineral/Coliform Bacteria(4391)Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE /V Domestic/Private CI Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> F1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK /1(New Well ❑ Replacement Well Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells i Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑Put-Of-Service Well a Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger i i Cable Tool ❑ Push Point I Other <br /> Proposed Well Depth&Vft Excavation 1,7AY in diameter ❑ Open Bottom ''Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter j�, in Thickness/Gauge/ASTM Sched SVR 2/ 11Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Zo ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /�• 3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) n Other <br /> Grout Placement Method Pumped Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By g Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width,f- ft Length ft Thick L <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ASubmersibleE Turbine ❑ Other HP Z Pump Set �`� ft. Standing Water Level 411V t7 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 gr 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 nn <br /> Application Accepted By Date �a tq67 1 Area Employee ID# F 1` <br /> Grout Inspection By �'m�i�ll� �cc�� f1,l�ii Date \Z(-t /'Ic;'Z1 ❑ SPECIAL Well Permit <br /> Pump Inspection By /ISLE o 1't Date L{ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS ke,id—,riiCr 1rsc;,ni^, C t-Jv1 -Aisf Well 0•,C a•- �ltor <br /> 4�261lz v4P1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice '' Viea <br /> Codes Info B ash Remitted Service Request# J �� <br /> ' s 90 o s i 4 Is-,;! 1 CID hail <br /> Ro CO/ <br /> 4S90 <br /> LI3q 1 # s C) �, Nr <br /> 1439 <br /> EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit <br />