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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL (ZUU) 903-f159/ FOR INSPECTIONS tXF'IKt5 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS 2955 Juliet Rd CITYIzIP Stockton/95205 <br />CROSS STREET Madrid Dr. ` APNII 17304007 f� PARCEL SIZE 5.22 LAND USE APPLICATION # <br />OWNER NAME Jag Sihota Sfl1 O ��7� $v: r1 rr S ih�+ ; Ay for C TA L. PHONE 706-613-0539 <br />OWNERADDRESS 11320 E Highway 120 CITY/STATE/ZIP Manteca/CA/95336 <br />CONTRACTOR West Coast Exploration Inc. PHONE 209-985-7541 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE/ZIP Escalon/CA/95320 <br />SUBCONTRACTOR CTE CAL Inc. <br />SUBCONTRACTOR ADDRESS 4230 Kiernan Ave Ste 150 <br />LICENSE x C-57 C-61 D-09 Other. <br />NUMBER <br />PHONE 209-543-1799 <br />CITY/STATE/ZIP Modesto/CA/95356 <br />870761 EXPIRATION DATE 01/31/2022 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings x Geotechnical <br />4 # of ty�y'n s <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Replacement Pum Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well <br />Depth 15 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Siz$� in is <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />ENV/ co)11 C <br />N6A,brr RDN CSN <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal <br />Depth i5 ft x Neat Cement (94 lb bag6-10 gal water) Sand Cement <br />sack <br />N <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped x Free Fall Other Retardant / Accelerator (name) <br />)EDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />n Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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 />NIISINil AI 24 IIOCR kD\'AN('F No I ICI: REQCIRED FOR INSPIX PIONS - I'LL NSF ('ALL (2119) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 1 4917 ,a <br />Grout Inspection ByDate <br />Pump Inspection By _414 -Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 5talkt<�� Employee ID# A <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount D ;te Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service Re uest4374 i- <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Permit <br />e4W --t IS 7S -7 / 0y 3 <br />m <br />m <br />D <br />v <br />v <br />m <br />Cn <br />rn <br />5 <br />