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1, EMAILED \ �U �-�� WELL/PUMP PERMIT SAN JOAO C fNvi NMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE.STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED \\ Joe ADDRESS 0_� ` W CITY/ZIP m CROSS STREET 1 �' 1 �` t/ APN lel S) 16, 7 PARCEL SIZE 1 CJ LAND USE APPLICATION# / p OWNER NAME �� C L L PHONE )J -� )-�J C II��'C� M OWNER ADDRESS _ V-C! I�C, I )�� CrrY/STATE/ZIP Lotti CA 9 5a41 CONTRACTOR ti ', /C 1� 1 rl c) _ PHONE_ ( r� C� �77(� CONTRACTOR ADDRESS C- C'n 4 _ CITYISTATE/ZIP �-'�1 CA SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE '-,/,.C-57 C-61 D-09 Other NUMBER '7cl 1 3 EXPIRATION DATE / 1 —1 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ' Irrigation/Agricultural X Industrial Water Quality Monitoring ' Soil Sampling/Characterization Public Water System ^1 r If different from Owner. Water System Name Contact Name or Phone Number cc TYPE OF WORK New Well Replacement Well ^u Well Alteration/Modification Other CD Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings Geotechnical #of 1>040 Out-Of-Service Well D Out-Of-Service Well Renewai Cross-Connection Repair SAN New Pump Pump Replacement PUMP e ' Raise Well Casing E q Q WELL CONSTRUCTIONt �T/yD N/17EN UNTy Drilling Method;Mud Rotary Air Rotary Auger ab Gal Push Point Other Fp�RT E Proposed Well Depth �Z) ft Excavation In diameter Open Bottom ,*Gravel Pack/Gravel Size f 4 in diameter NT Conductor Casing in diam r / Conductor Casing Depth ft Well Casing Diameter C) in Thickness/Gauge/ASTM Sched C . Steel .X Plasfic Stainless Steel Other Grout Seal Depth !( ( ft Neat Cement(94 lb bag/5-10 gal water) ;Sand Cement I C 3 sack mixR gal water Bentonite(20%solids) Other Grout Placement Method;K Pumped LlFree Fall Other Retardant I Accelerator(name) PEDESTAL Installed By ';4 Driller D Pump Contractor Other Concrete Pedestal,]Dimensions:Width—3—ft Length ft Thick in Christy Boz Stove Pipe PUMP Submersible Turbine - Other HP7 1/.� Pump Set-�ft Standing Water Level 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 bomestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. MINf)Il Hit IRAl)�AN(A NO11CLRLQL,IRLUIORINSPLCIIONS-PLLASLCALL 120919;3-7691 ��j�(IIIARTMENI USE N L Y j�} A Application Accepted By�'"S��r!,E —� Date /Z7 z Area /7 / Employee ID# ,V�� Grout Inspection By �1 _ Date '��2 _ SPECIAL Well Permit Pump Inspection By_ �� Date �2 L WAIVER Received _ Soil Boring In pedion By Dae Constructed Well Depth Z�� ft COMMENTS (5 � p wo u P ar- ice s' Aa,-1 Z cze—c /e t e-,- V e4 PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info as Remitted Service Request It ' � i Zo . q.a4 0m45 38�L 3$� 051 11107, 3 •J4 P FIIDD43-06 0107,2022 Page 1.1`2 Pell i P—P rmmr