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,• S-bockion `45c?iR <br />PARCEL SIZE a tio LAND USE APPLICATION # <br />Installed By 0 Driller 0 Pump Contractor <br />Concrete Pedestal ODimensions: Width <br />Christy Box 0 Stove Pipe <br />0 Other <br />ft Length ft Thick <br />PEDESTAL <br />in <br />Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings Geotechnical <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump ISt Pump Replacement CI Pump Repair O Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger <br />Proposed Well Depth <br /> <br />ft Excavation <br /> <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel <br />Grout Seal Depth ft ID Neat Cement (94/b bag/5-10 gal water) <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall El Other 0 Retardant / Accelerator (name) <br />PUMP Submersible° Turbine 0 Other HP I VI 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 />TYPE OF WORK 0 New Well CI Replacement Well 0 Well Alteration/Modification 0 Other P4 o <br />f bft COit jo. <br />PR 0 <br />41/VJ 1 202? <br />104490er <br />Op,‘,414—‘41:114414' <br />"1ff is Other <br />sack mix/7 gal w7aAr <br />0 Cable Tool 0 Push Point 0 Other <br /> in diameter 0 Open Bottom 0 Gravel Pack/Gravel Siz <br />ft <br />Plastic 0 Stainless Steel Li <br />El Sand Cement <br />Area 4 Employee I D# t- ET- <br />D SPECIAL Well Permit <br />El WAIVER Received <br />Constructed Well Depth ft <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DE A TMENT USE0 LY <br />Date <br />Date <br />Date <br />Date <br />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 <br /> <br />83(v3 -Treasure, Ave. <br />;c0,(6 APN g 5 3 Z°2, <br />'6emard Suso.nna_ <br />83(03 "Treastine Ave <br />k.koor man's U.DekAe)i ms - <br />allaO 141(7coc Rd CONTRACTOR ADDRESS <br />PHONE i01— IN- 31 `Lk <br />5-/-cthfcsyl CA- 95cWQ <br />PHONE C2Of '75/,-3c/ o <br />51rxkiryn C4- 95;/5- :SSMIGOV 311S JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br /> <br />PHONE NA1-3 <br /> <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> <br />LICENSE /ik C-57 0 C-61 0 0-09 0 Other NUMBER 1168g/49 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliforrn Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE Domestic./Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br /> <br />If different from Owner: Water System Name Contact Name or Phone Number <br />PE SC <br />Info By _ <br />Received(Check Amount <br />Remitted <br />Permit/ Invoice # Well ID# <br />L . <br />iCtlyi <br />0 9) Z./42— /4/24, --7-- <br />, i Dite <br />III 12 <br />, Servic9 pgieisl 57.. <br />1ATOO`r3 <br />EHD043-06 10/25/2021 Page I of 2 Well/Pump Permit