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0 I WELL/PUMP PERMIT [/'� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205��- � 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UED JOB ADDRESS �7 Jo L CITY/ZIP /TL��7�� O CROSS STREETX,�WZ�Ce�a/g w* AP ,rr/ APN /1 J �� PARCEL SIZE O //�J �Z.30- � 6v LAND USE APPLICATION# o A OWNER NAME ,��Q/ //7�j�/// Lt PHONE7�✓�7J' (n OWNER ADDRESS CITY/STATE/ZIP QA�/*} %SZZO CONTRACTOR /Y p`j/f �,Q/ //7f /I:�. PHONE 2,!/s77Z- Z7 5-7 CONTRACTOR ADDRESS 6IX �j�d/ CITY/STATE/ZIPA�14/ SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE xC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ZDV 7D 713 EXPIRATION DATE /O'-V—ZD ZZ DOMESTIC WELL SAMPLING:g General Mineral/Coliform Bacteria(4391)y Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 0 Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK X New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #ofborings ❑ Geotechnical #of borings [],Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method A Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point D Other Proposed Well Depth —CO ft Excavation /,?Ay in diameter ❑ Open Bottom 11 Gravel Pack/Gravel Size_ in diameter 0 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 41 in Thickness/Gauge/ASTM Sched; ,e-7/ ❑ Steel A'Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth__,10 ft 0 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement ��• 3 sack mix/7 gal water 0 Bentonite(20%solids) 0 Other Grout Placement Method Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By gDriller ❑ Pump Contractor ❑ Other 0 Concrete Pedestal❑Dimensions:Width,S ft Length�_ft Thick L in 0 Christy Box ❑ Stove Pipe PUMP A Submersible❑Turbine ❑ Other HP Z Pump Set I q1V ft Standing Water Level 41"0 —` 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. NIININIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 DEPARTMENT USE ONLY n Application Accepted By .--T�� Date 12 lq71 Area L �C Employee ID# f I� Grout Inspection By m9i�t(� (oo�J;0 1t>�ii Date_ ,ZIZ 12c,'L1 ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth COMMENTS Re-gJ44-coce diseoji4jclr I!J , cii Well 4nd r"wripcT, ' r I L v-101- PE -11 ..PE SC Received Check#/ Amount Date Permit/ Invoice;V'`IIV ell,' Codes Info B ash Remitted Service Request# J, 3 gn o s 1 a 114124 r l)U 2 h No y CO 4 66 8 0 oFp y.T-c LI39 I # s v k. I � Nr 43 $ -7p I - EHD043-06 10/25/2021 Page I of 2 Well/Pwnp Permit