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I p 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL (ZUU) UbJ-1b9t FOR INSPECTIONS t:APIKhb 'I YEAR FROM DATE ISSUED <br />\ w-% ► N .\ o \ h r % % . - 1-1 n <br />JOB ADDRESS 1t1111111lux INJW'KVN K\\P9\LW1 CITY/ZIP <br />CROSS STREET _OL�\\t APN o� �� ]^ \ �lJ '✓��i (/t.�� PARCEL SIZE �AND USE APPLICATION #j <br />OWNER NAME C,�,1 CJ"r (—'f(i(1 PHONE ( 26N \1" /\-'1 S Ll <br />OWNER ADDRESS 00-i .41 z �k\r e k CITY/STATE/ZIP _160�AOA , CA \ J W L <br />CONTRACTOR V O�),\t�t1\ (\(,. PHONE LAIM46c-k- 7-70o <br />CONTRACTOR ADDRESS > g\r.Ik)(-1nut-'A \,J _ CITY/STATE/ZIP 61a\­� r` A C" SIbS2_ 7 <br />SUBCONTRACTOR `0 \\GVe_ � f�L}�(Xi�UtQ� \ PHONE_ <br />SUBCONTRACTOR ADDRESS �L/—JLJ �V\C.\V� \G� r,�li\�tC�$ CITY/STATE/ZIP CA q5c <br />LICENSE -A C-57 ❑ C-61 n D-09 ❑ Other. <br />NUMBER I ! �' EXPIRATION DATE V _\ I y) 207 q <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I_] Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical # of borings <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Ll New rump a rump Kepiacement u rump Kepair a raise vven easing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary )� Auger ❑ Cable Tool I 1 Push Point ❑ Other <br />Proposed Well Depth N 5 ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft PAYMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched a Steel a Plastic ❑ Stainless Steel ❑ Otf <br />Grout Seal Depth1c�ft 15, Neat Cement (94 Ib bag/5-10 gal water) [I Sand Cement r <br />1-1 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ PumpedFree Fall *Otherkl'Q(` C 'vV q'IU ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller P Pump Contractor ❑ Other SAN JOAQUIN CQLI <br />Li Concrete Pedestal uDimensions: Width ft Length ft Thick ENVIRONMENTAL <br />in ❑ Christy Box ❑ Stove Pipe HEALTH DEPARTMEN <br />PUMP ❑ Submersible❑ Turbine ❑ 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 />MINI \ 111 NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9.53-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Z�� L Date 7/7;,�? <br />Grout Inspection By <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date ' 2 <br />COMMENTS <br />Area J1 k to Employee ID# <br />[ SPECIAL Well Permit <br />1.1 WAIVER Received <br />Constructed Well Depth <br />ft <br />77 <br />PE Sc Receive <br />Codes Info A y <br />Che k#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request! <br />9379 isr) <br />EHDO43-06 04/07/2022 Page I of 2 Well / Pump Permit <br />