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Feb, 18. 2022 1:30PM wager dairy No, 8493 P. <br />1 WELUPUMP PERMIT <br />SAN JOAQUIN CouNYY ENVIRONMENTAL HEALTH DEPARTMENT <br />1860 EAST HAZELTON AvENuE - STorKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM ATE ISSUED <br />25823 E Carter Rd <br />cln/ZlpEscalon, CA 95320 <br />�0, ADDRESS <br />CROSS STREET Singer Rd APN 187-250-007 <br />_PARCI I SRE � 1 V LAND USE APPLICATION# <br />OWNER NAME Jarred Mello <br />PHONE (209 573-3748 <br />OWNER ADDRESS PO Box 22 <br />CrrYlsrATElziP Escalon, CA 95320 <br />(CONTRACTOR BSK Associate <br />PRONE (209) 769-4734 <br />CONTRACTOR ADDRESS 550 W Locust Avenue <br />Crrv15TATF1zIP Fresno, CA, 93650 <br />SUBCONTRACTOR BSK Associates <br />PRONE (209) 769-4734 <br />550 W Locust Avenue <br />Fresno, CA, 936510 <br />ADDRESS <br />_ Cnv/STATElziP _ <br />,SUBCONTRACTOR <br />LICENSE 9 C-57 ❑ C-61 U D-09 EIOther .� <br />NumaER 490942 EXPIRATION DATE 12131(2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) <br />❑ Dibrornochtoropropane (4392) ❑ Arsenic (4393) <br />INTENDED lysg ❑ ornestic/Private ❑ Irrigation/Agricultural ❑ Industrial <br />❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner: Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well d Well Aiterati4FVModification ❑ Other <br />❑ Monitoring Well(s)—#of wells ❑ SoilBoring(s) aofborings NGeotechnical4X10' #otnrings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Reoair ❑ Raise Well Casing <br />g <br />O <br />m <br />41 <br />Drilling Method 0 Mud Rotary C Air Rotary J Auger ❑ Cable Tool ❑ Push Point >(X Other Hand auger bori ngs <br />Proposed Well Depth � 10111 Excavation 4" _ In diameter ❑ Open Bottom ❑ Gravel Pack/Graval Size in diameter <br />❑ Conductor Casing in diameter I Conductor Casing Depth it PA <br />Well Casing Diameter _ in Thickness/Gaugo/ASTM Sched ❑ Steel n Plastic ❑ Stainless Steel 7, Other T <br />Grout Seal Depth j J It 1.55 Neat Cement (94 Ib bagl5-10 gat water) ❑ Sand Gement sac 1 �I r / <br />r] Bentonite (20% solids) 0 Offier " D <br />Grout Placement Method 0 Pumped M Free Fall ❑ Other T_ ❑ Retardant I Acc-09ralor (name) <br />PEDESTAL <br />Installed By ❑ Driller ❑ Pump Contractor <br />❑ Concrete Pedestal ❑DImonslons: Width , <br />❑ Christy Box ❑ Stove Pipe <br />❑ Other_ <br />It Length <br />ft Thick <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set __ ft Standing Water Level _ <br />Plot Clan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GFS <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 2001 radius of proposed well. <br />MINIMUNI 241101111 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7691 <br />DEPARTMENT USE ONLY <br />Appucanen Acceptea by ��iz Z- G- Aron Ll q6 Gmployea IDH `t <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date ❑ WAIVER Received <br />Date V5 PA A QRZ Constructed Well Depth <br />ft <br />Ty <br />PE <br />Codes <br />— S Received Check#1 <br />Info _ Ca h <br />Amount <br />Remitted <br />pate <br />PermlU <br />Service Request _ <br />Invoice # <br />Well ID# <br />Elltwa1.06 NV25l2021 �� r aez WOU cusp rami <br />