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1 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS I EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 176`I M e-A 1 e.r D CITY/ZIP L UCS 1 , /� C� J, I m Y`► z CROSS STREET Cj I`1 L n . APN U r �f-I I S. PARCEL SIZE 3�C LAND USE APPLICATION# g + 1_ ( ` m OWNER NAME P k e r G\`A S N PHONE '?('I - y J�t7( — v J J�' N N OWNER ADDRESS CITY/STATEIZIP \ CONTRACTOR S)•�\ 1 C�, �)�1 ,�(� 1 PHONE , ,_,-1 3(.9 - _?77 t CONTRACTOR ADDRESS (� O II;C}( `i u{ CITY/STATEIZIP �l�i 1 i C'A q S C,-,_S ;� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTA'TF/ZIP ^� LICENSE C-57 U R 1 C-61 U D-09 ❑ Other NUMBC16 �I3 EXPIRATION DATE 7 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)4 Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE 'ADomestic/Phvate ❑ Irrigation/Aghculturat Cl Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization Cl Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ')�New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Borings) a of borings ❑ Geotechnical n of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump D.Pump Replacement U Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method �(Mud Rotary ❑ Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ^k 1% ft Excavation 12 in diameter ❑ Open Bottom �9 Gravel Pack/Gravel Size 1/4 - in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter , in Thickness/Gauge/ASTM Sched CI ❑ Steel Plastic ❑ Stainless Steel ❑ Other Grout Seat Depth _Ay') ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fail ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By 1-Driller ❑ Pump Contractor ❑ Other _ Ix cffl �i Concrete Pedestal[I Dimensions:Width 5 ft Length ft Thick �in n Christy Box ❑ Stove Pipe MU n uMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Lsye Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followft'1#ei4$',�(1ePS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, st4't res, potential sources of contamination,sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. NN%,1111 1i ?.111!11 N ''%DN 0(1 1011! 1 Vi QI IHI D1011. 11 1'1 i I lid'", I't I V',I i / DEPARTMENT USE ONLY Application Accepted By — — 1� Date L'�ei J Area I�j Employee ID# Grout Inspection By Date 5� t `Z-Z ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS Fr vve) ,? 1 f'( wler "rc:.c t f� In �'! 6 PE SC Received �C*IheckW Amount Date Permit/ Invoice# Well Ill Info B Cash Remitted Service Re uest# V ` `43c1 i 3 P0 D 13C 0 2-52 EI-11)(143-0610125i2021 �_ � Page l of22 L�/i� � �� 15'e11 l Pump Punu,