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DocvSign Envelope ID:5A0250AA-8234411F-Bl7E-8E9A834155BC <br /> ` 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 t� EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS �1/�D� � �Gt i.�- CITv/ZIP f'�l Ib V) 4 <br /> M O , /�-- T 9 D <br /> CROSS STREET �IC)�(,/l,L �n A1PN9-4C– �au PARCEL SIZE / • C7 LAND USE APPLICATION# 1 0 <br /> OWNER NAME `Jrn V) �I G( �b 1.� ` I�1--l7— PHONE go Il t��tD—&'gw y <br /> '7 /�� I. n f� J <br /> OWNER ADDRESS �-e ` 1,9SO (,C,.'11-0 ICyI �� CITY/STATE/ZIP�IWVIYAill�lCll# qo�]Q7 <br /> CONTRACTOR "rO—YC h 9S166 PHONE 2N 22&9- bi(Q-f <br /> CONTRACTOR ADDRESS ` W6D- Iib CITY/STATE/ZIP <br /> SUBCONTRACTOR Na PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE A C-57 LI C-61 Li D-09 Ll //"lOther NUMBER �� '1 6 EXPIRATION DATE "I <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 9 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ 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 ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud ry ❑ Air Rotary ❑ Auger 1 Cable Tool ❑ Push Point Ll Other <br /> Proposed Well Depl ft Excavation I;)- - in diameter ❑ Open Bottom rGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM SchedSpR.�–( L Steel >C Plastic a Stainless Steel a Other <br /> Grout Seal Depth ft L Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method kPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name)_ <br /> PEDESTAL Installed By J Driller ❑ Pump Contractor ❑ Otherray T <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick p <br /> in L Christy Box Stove Pipe <br /> PUMP Submersible_i Turbine ❑ Other HP Pump Set ft Standing Water Level 023 <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followmMB C�R C UNTY <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wel s,9WIRf�&E TAIL <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. *WAQPFP&1#rAR WENT <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200' radius of proposed well. <br /> NIINLNII N1 24 1101 R:NI)N ANCL NO'FICF RF.QI IRFU FOR INSPEC I IONS-PI,}C;ASI;CAI.1.(209)953-769? <br /> EPARTMENT Uiii1§ E O LY <br /> Application Accepted B Date O Z Area-- 19 9 Employee ID# <br /> Grout Inspection By Date i SPECIAL Well Permit <br /> Pump Inspection By Date ! WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Reque # <br /> y36lo /�ON4, IS I <br /> YS <br /> 9Z <br /> EHD043-06(4/072022 Page I of 2 Well/Pump Perron <br />