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1 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 /> &1-81 Ln <br /> JOB ADDRESS LY-50 y0'f�{v�j�k, A CITY/ZIP -33 m <br /> D <br /> CROSS STREET <JAr~ APN off'!"c1?0—,Z0'6b0PARCEL SIZEM611,11-AND USE APPLICATION# <br /> OWNER NAME / � � (> ' fl/ �15 / `, n ' rn <br /> �` , /�v J� r�� �,lPHOyNE l L���/3J �d�l�� vi <br /> OWNER ADDRESS - T'� W I--A>Vl S47 A:&A- O t CITY/STATE/ZIP/"LG,../cC.� L '70W <br /> CONTRACTOR c[�=1 h / 1 PHONE //� <br /> CONTRACTOR ADDRESS 2�2✓ I J ) � / Id Vr. ��� CITY/STATE/ZIP (itwb. CY (�� eyl <br /> SUBCONTRACTOR �v�lLl� ' vlM � 5ye'V1.41. PHONE <br /> SUBCONTRACTOR ADDRESS �© � rim �¢vv CITYISTTATE/ZIP 1r��5 C rt576 t r <br /> LICENSE l/G57 C-61 D-09 ❑ Other NUMBER ;5�1-1//S if EXPIRATION DATE G/3q/23 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private .:: Irrigation/Agricultural Industrial 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 /> 0 Monitoring Well(s) #of wells :_ Soil Boring(s) #of borings Geotechnical v #of borings <br /> G Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> C New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> !Drilling Method Mud Rotary Air Rotary Auger Cable Tool `_f Push Point Other <br /> Proposed Well Depth ft Excavation " in diameter Open Bottom -:: Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel L Plastic Stainless SteePAWVE ' <br /> Grout Seal Depth `- CJ ft Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement- <br /> .911� gal water <br /> Bentonite(20%solids) ❑ Other REe <br /> Grout Placement Method 0 Pumped - Free Fall )w Other C)C Retardant/Accelerator(name) <br /> I -i LULL <br /> PEDESTAL Installed By �. Driller 0 Pump Contractor ❑ Other_ <br /> Concrete Pedestal CDlmensions:Width ft Length ft Thick SAN JOAQUIN COUNTY <br /> in Christy Box C Stove Pipe ENVIRONMENTAL <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 /> NIINI�IPNt 24 H(;i..R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9.53-7697 <br /> DEPARTMENT USE ONLY <br /> l� C-7 <br /> Application Accepted By - V Date �J� 2� Area ! Employee ID# <br /> Grout Inspection By L Date C SPECIAL Well Permit <br /> Pump Inspection By Date Z n E WAIVER Received <br /> Soil Boring Inspection By 4 Date 2- J 11L`�L,� � ' LConstructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info B C sh Remitted ate Service Request# <br /> LHD(WL0604/07/2022 page I'f2 Rall-Punp,Permit <br />