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I WELLlKl1 "ERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />.,�.. .. <br />rUMUMOLC 17C111111111 (;ALL ZU9 953-7597 FOR INSPECTIONS EXPIRES I YEAR FROM DA�TE\ISSUEC <br />,IQB ADDRESS p� -7 CITY/(ZIP fC .i w(, <br />CROSS STREET nn r r' �Y % APN aO 5 ,2 ( d V a PARCEL SIZE vl . 6 LAND USE APPLICATION # <br />OWNER NAME `L O - i/ t/G/l zyale i �/ /!/G� PHONE 0 ^ (� <br />OWNER ADDRESS sor, on e -4 S a go v C CITYISTATE/zIP p `� <br />CONTRACTOR ��PHONE <br />CONTRACTOR ADDRESS 3 LI�0- -- CITYISTATEIZIP 3 <br />SUBCONTRACTOR _ _ PHONE <br />SUBCONTRACTOR ADDRESS _ _ CITYISTATEIZIP <br />LICENSE L Ie57 _ C-61 L D-09 Other NUMBER EXPIRATION DATE'51 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private i irrigation/Agricultural Industrial ; Water Quality Monitoring i Soil Sampling/Characterization <br />I Public Water System QA <br />If different from Owner Water Systom Name Canacl Name or Plmne Number <br />TYPE OF WORK F New Well - Replacement Well F Well AlterationlModification <br />F Monitoring Well(s) # of wells r- Soil Boring(s) <br />ut-Of-Service Well Out -Of -Service Well Renewa <br />New Pump i Pump Replacement I Pump Repair <br />C Other <br /># of Wrings Geotechnical <br />I r Cross -Connection Repair <br />_fF of bonpgs,)v 2 <br />Qw.. V <br />N <br />a <br />°v <br />M <br />y <br />..cu vvrvartw uvry NFq SIRpN INC <br />Drilling Method I Mud Rotary i Air Rotary Auger Cable Tool i Push Point Other T M <br />Proposed Well Depth ft Excavation in diameter ! Open Bottom Gravel PacklGravel Size in 1, <br />' <br />C Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ISteel Plastic Stainless Steel i Other <br />Grout Seal Depth ft Neat Cement (94 Ib ba_W5-10 gal water) Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) Other <br />Grout Placement Method i Pumped . Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ! Driller Pump Contractor IOther <br />! Concrete Pedestal :Dimensions: Width ft Length it Thick <br />in ! Christy Box i Stove Pipe <br />PUMP ti015ubmersibiei Turbine i Other HP Pump Set -J6_0 ft Standing Water Level _kj2_ 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 tines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />111\1111 �I ?1 IIUI R:1U1 ;\�{'i: X117 I(.t: RF;(,il'IRED PnR ItiSPECTin\5- PLE:ISF (':1L1. t?!191 9�3•?69? <br />DEPARTMENT USE ONLY LL'' <br />Application Accepted By Z— jr Date _ C .51 i ;R Area 1 Employee ID# _ <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By Date 2'-L WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />tJ <br />COMMENTS evJ Wt 11 CplrMtl� �rJ P�O�o�7% y391 3 143g..�i/Y! <br />?PAit�p_ Cocg¢Q�Np,tts of W_E'.— <br />PE Sc Received <br />Codes Into <br />Check#/ <br />Gash <br />Amount <br />Remitted _ <br />Date <br />Permit/ <br />invoke # WeI11Da: <br />Service Request # <br />LHIX•43.0604VT2022 <br />Heil /Pump r�Kmn <br />C�ff <br />