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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUN <br />JOB ADDRESS <br />3LE PERMIT GALL ZU`J U04-/OUI FUR INSPEGIIUNS CAr1KCJ l TtAK FKU,Y, UAIt ISSUtU <br />22176 E. Skiff RD crrY/z,PEscalon, CA 95320 <br />CROSS STREET Temple Creek Rd APN 205-200-062 PARCEL SIZE r,s$ LAND USE APPLICATION # <br />OWNER NAME WA GNFiI.yh.a� !J/l�r.' 1 ,F�5 L �4 PHONE vU ' E7rS -SOC# <br />OWNER ADDRESS ;�Zj 7 -.ir'-zF %L,p, CITY/STATE/ZIP EisCAZ-v�, C.A Cg 3 2.0 <br />CONTRACTOR BSK Associates PHONE (209) 769-4734 <br />CONTRACTOR ADDRESS 550 W Locust Avenue CrrY/STATE/ZIP Fresno, CA, 93650 <br />SUBCONTRACTOR BSK Associates <br />SUBCONTRACTOR ADDRESS 550 W Locust Avenue <br />LICENSE A C-57 I C-61 ❑ D-09 J Other. <br />PHONE (209) 769-4734 <br />CITY/STATE/ZIP Fresno, CA, 93650 <br />NUMBER 490942 ExnRATION DATE 1 2/31 /2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE -1 Domestic/Private ❑ Irrigation/Agricultural Industrial C Water Quality Monitoring ❑ Soil Sampling/Characterization <br />ij Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well 7 Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells -1 Soil Boring(s) # of borings X Geotechnical 4X101 sof borings <br />❑ Out -Of -Service Well _l Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />,1 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method it Mud Rotary ❑ Air Rotary ❑ Auger a Cable Tool F. Push Point X-C Other hand auger borings <br />Proposed Well Depth 10 ft Excavation 4" in diameter -1 Open Bottom F Gravel Pack/Gravel Size diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft Iq Y <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched -1 Steel ❑ Plastic 1 ! Stainless Steel ❑ Other <br />Grout Seal Depth i0 ft X Neat Cement (94 lb bag/5-90 gal water) ❑ Sand Cement sack mix17 <br />I _! Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped X Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By a Driller 1-: Pump Contractor C Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP L' Submersible❑ Turbine C Other HP Pump Set ft Standing Water Level ft -'I <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 />NnNrNIUNI 24 HOUR ADVANCE NOTICE REQUFRFD FOR INSPECTIONS - PLEASE CALL. (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �� - Date 3 3 Area y Employee ID# A G <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date <br />"� ❑ WAIVER Received <br />Soil Boring Inspection By Date �_.v�r Constructed Well Depth ft <br />COMMENTS /_1_Ph" / p <br />PE <br />Codes <br />Sc Received Check#/ Amount Dae Permit/ Invoice # Well ID# <br />Info B Cash Remitted Servi uest# <br />EliDD43-06 10.25/2021 Page I uf2 <br />&V -�/39P36 2v2. <br />Well; Pup Pe—if <br />