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R 1' WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT y/%l Q I J ( )CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS C ! `-J / CITY/ c / ` / ✓ l CROSS STREET 10 6 ^ APN ll? CN - 0) '? PARCEL SIZE �� I NAND USE GJAPPLICATION %# OWNER NAME In I L4 �/ , (Anche Z /—P�HyOo�`NNEE,Vj( ` / � V -33-73 OWNER ADDRESS �'/ ! vl {� U U CITY/STATE/ IP + t/ " t a qsa I S CONTRACTOR A1 / 1 / { I y -e 'S J— '/ L PHONE �--I V CONTRACTOR ADDRESS 1 C l 1/l / ✓ CITY/STATE/ZIP 0kdA UC C0 C7 ✓ L(/' SUBCONTRACTOR 11 � PHONE 91-A SUBCONTRACTOR ADDRESS I I/) n TY/STATE/ZIP A/ I- ,1 LICENSE XC -57 ,<C-61 _ D-09 Li Other D NUMB Eu 3^u_3 EXPIRATION DATE'`✓ D ZvQ-a, DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization _ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well I I Renlarement Well i I Well Alteratinn/Mndifiratinn i i C)ther d 1i. ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # Out -Of -Service ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair _ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION SA IV it I ?�Z? Drilling Method ❑ Mud Rotary Li Air Rotary ElAuger ❑ Cable Tool 11Push Point = Other ,f 9q Proposed Well Depth ft Excavation in diameter ❑ Open Bottom _ Gravel Pa / 41(lYJI N,'Unn�I�iameter _. Conductor Casing in diameter / Conductor Casing Depth ft PARTM C Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑Other ENT Grout Seal Depth ft I I Neat Cement (94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method Pumped I I Free Fall I I Other I I Retardant / Accelerator (name) PEDESTAL Installed By _ Driller ❑ Pump Contractor _ Other ❑ Concrete Pedestal -Dimensions: Width ft Length ft Thick �in Christv Box I I Stove Pipe PUMP x,Submersible Turbine I I Other HP L-, Pump Set I / U ft Standing Water Level I ✓ U 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 LIUUR ADVANCE NOTICF REQL:LRED FOR INSPECTIONS - PLEASE, CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By Z� L— Date Area f C 9 Employee I D# Grout Inspection By Date ❑ SPECIAL Well Permit t, Pump Inspection By /Af�!Date di ❑ WAIVER Received Soil Boring Inspection By COMMENTS DU[v'Men} �nr,�CAIn Constructed Well Depth Lf -I - a ft T m v 0 M M 0 O R, PE Codes Sc Received Chec Info V sh Amount Date Permit/ Invoice # Well ID# Remitted Service Re uest # N38 ► o s o 7 I Z2 D EHIN43-06 10/25/2021 Pape I of 2 Well /Pump Permil