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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 /> JOB ADDRESS L�50 G� a1 YOSc�� IC ,c,NC. CITY/ZIP i�L � �s 3 " 'L <br /> Ln <br /> nn � D <br /> CROSS STREET / c: vc. APN a �- (7 O '�IX7 x-:)PARCEL SIZEI�J.bU c.LAND USE APPLICATION# /t J/ o <br /> OWNER NAME C.^(mac G �//iv„ c!" +�+Jl �, {/ �r f PHONE f L lY; /}�ry j - � `J� vy <br /> OWNER ADDRESS ��' ln� lac f S<- c, ..y�. CITY/STATE/ZIP ALLtiJc[1 �� !✓)1 <br /> CONTRACTOR i �( // 1) )) PHONE_/�W 'j/]—�{JJ�j <br /> CONTRACTOR ADDRESS ��.�J � �✓G�'�� �o�l�c Vr��l� CITY/STATE/ZIP r/r'G1�':•�j L-A rt ! ! <br /> SUBCONTRACTOR �VrGL� ��vltil eSsG�'%G `S { PHONES'// <br /> SUBCONTRACTOR ADDRESS � l)y -n.F�c.��.�lc / ��y'-�¢vr, /� C <br /> I�TY/STATE/ZIP V 1Ic5 I c/� rile•. /7 ( �) �5C 1 <br /> LICENSE V C-57 C-61 11D-09 Other NUMBER 0rI/ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE - DomestiGPrivate ::: 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 a New Well : Replacement Well C Well Alteration/Modification Other <br /> C Monitoring Well(s) #of wells C Soil Boring(s) #of borings Geotechnical �%' #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement C Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _: Mud Rotary Air Rotary _ Auger Cable Tool Push Point Other <br /> Proposed Well Depth Ci 0 ft Excavation 2 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 C Plastic Stainless Steep <br /> Grout Seal Depth ft Neat Cement(94 Ib beg/5-10 gal water) ❑ Sand Cement tt�rso r�yfidt-Fr 7 gal water <br /> _ Bentonite(20%solids) Other --� " <br /> Grout Placement Method Pumped Free Fall Other rrc=� sC� Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal -Dimensions:Width ft Length ft Thick SAN JOAQUIN COUNTY <br /> in :_: Christy Box Stove Pipe ERVIRONh4rNTAL <br /> PUMP SubmersibleEl 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: CPS <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 /> NIININtUNt 24 NOUR:ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By V v Date Area� / Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date l WAIVER Received <br /> Soil Boring Inspection By f�• -�— Date y L Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B C sh Remitted Service Re uest# <br /> I !J <br /> I-HD(u3-(W 04 0 2022 P.rgv I o'_ Ndl Puny+Prmur <br />