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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT [ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5/ ✓ 2 E M-e 1- s c-1 Z CITYIZIP <br /> '� � <br /> CROSS STREET I�r (1 f �C'� �,q�. KD APN C�C'� I PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME CM 1 \U �C't 4 C� PHONE 9,A �'•''�7 <br /> OWNER ADDRESS \ ,-J(-\..A a CITY/STATE/ZIP .�C�'''�1 Q�\. C3L, <br /> '-,� CI S�j-o-C <br /> CONTRACTOR V�1�12'y !� L X11 X11�� /PHONE 2(_,� ` L,Cj '!�/—I7 /7 q <br /> CONTRACTOR ADDRESS �C" CITYISTATE/ZIP ` I}`f C A q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE AC-57 J C-61 11D-09 7 Other NUMBER r?143 J7> EXPIRATION DATE 7 <br /> DOMESTIC WELL SAMPLING:� General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) pq <br /> INTENDED USE )k Domestic/Private LJ Irrigation/Agricultural �-1 Industrial 7 Water Quality Monitoring D Soil Sam pling/Characteriza CF /V7- <br /> Public Water System / /> <br /> If different from Owner: Water System Name Contact Name or Phone Number CJ <br /> TYPE OF WORK New Well :1 Replacement Well Ll Well Alteration/Modification ..I OtherO ? <br /> C Monitoring Well(s) #of wells ❑ Soil Boring(s) a of borings 'J Geotechnical A>AbO ag C <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair _ HEAL r/RpN/CO NT <br /> New Pum Ll Pump Replacement 11 Pump Repair 7 Raise Well Casingf1 DE ENT- Y <br /> WELL CONSTRUCTION N NT <br /> Drilling Method A Mud Rotary 2 Air Rotary 7; Auger ❑ Cable Tool j Push Point Other <br /> Proposed Well Depth "23o ft Excavation 1_ in diameter -1 Open Bottom �K Gravel Pack/Gravel Size IJA- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (,, in Thickness/Gauge/ASTM Sched C1.2L0 -1 Steel )kPlastic 7 Stainless Steel 7 Other <br /> Grout Seal Depth I E U ft ] Neat Cement(94 Ib bag/5-10 gal water) Sand Cement_]6.5 sack mix/7 gal water <br /> Bentonite(20%solids) 7 Other <br /> Grout Placement Method )4,Pumped ! Free Fall 7 Other I Retardant I Accelerator(name) <br /> PEDESTAL Installed By >(Driller 7 Pump Contractor ❑ Other <br /> 1 Concrete Pedestal=Dimensions:Width-3--ft Length ft Thick <br /> �in 7 Christy Box I Stove Pipe <br /> PUMP XSubmersible,.i Turbine -_1 Other HP__j_ Pump Set ft Standing Water Level 1 Or; 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 /> SHNIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTTONS-PLEASF.CAI.f.(209)953-7697 <br /> D PARTMENT US NLY <br /> Application Accepted By, Date �� ?'Z Area Employee ID# <br /> Grout Inspection By 5 Date \�i`�,S 1�,� SPECIAL Well Permit <br /> Pump Inspection By ^I��SE���' /l E� Date 1 "�S''2 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Ca emitted Date Service Request# Invoice# Well ID# <br /> O � /S(✓ lr I, <br /> 76 <br /> l <br /> LHU043-06 04;07/2022 Page 1 of 2 Well/P"MP Permit <br /> �7 I'• Vl'� ( k'(A ttll <br /> ��,Ir; IVY <br />