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I WELUPUMP 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 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 22510 CA -4 CI rbp Linden, CA 95215 <br />CROSS STREETS. Hewitt Road APN 183-340-010 PARCEL SIZE a P LAND USE APPLICATION X <br />OWNER NAME Lagorio Properties PHONE (209) 982-0734 <br />OWNER ADDRESS 777 N. Pershing Avenue CITYISTATE/ZIP Stockton, CA 95215 <br />CONTRACTOR BSK Associates <br />CONTRACTOR ADDRESS 550 W Locust Avenue <br />SUBCONTRACTOR BSK Associates <br />SUBCONTRACTOR ADDRESS 550 W Locust Avenue <br />LICENSE X C-57 C-61 _ D-09 Other <br />PHONE (209) 769-4734 <br />CITYISTATE/ZIP Fresno, CA, 93650 <br />PHONE (209) 769-4734 <br />CITYISTATE/ZIP Fresno, CA, 93650 <br />NUMBER 490942 EXPIRATION DATE 12131 <br />1 /2022 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE n Domestic/Private - Irrigation/Agricultural n Industrial - Water Quality Monitoring = Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Plane Number <br />TYPE OF WORK New Well = Replacement Well -7 Well Alteration/Modification Other <br />Monitoring Well(s) # of wells -Soil Borings) <br />/ of borings X Geotechnical 3X 10' 0 of borings <br />Out -Of -Service Well _ Out -Of -Service Well Renewal - Cross -Connection Repair <br />New PumD ; Pumo Replacement i Pumo ReDair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary _ Auger Ll Cable Tool IPush Point X Other hand auger borings <br />Proposed Well Depth 10 ft Excavation 4" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft A <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel - Plastic Stainless Steel : Other <br />Grout Seal Depth I'll S Neat Cement (94 lb bag/5-10 gal water) - Sand Cement sack <br />- Bentonite (20% solids) ❑ Other <br />Grout Placement Method .1 Pumped 14 Free Fall C Other 7 Retardant /Accelerator (name) M.I <br />PEDESTAL Installed By , Driller D Pump Contractor - Other — - J 7 <br />Concrete Pedestal FDimenslons Width ft Length It Thick —� <br />lin Christy Box :) Stove Pipe <br />Pump Submersible[: Turbine 0 Other HP Pump Set It Standing Water Level _Zg= _12's <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: G N / <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 />\IINJNI lNJ 24 HULR kf)% AV( F, NOTICE RF.QCIRFD FOR INSPECTIONS- PLF % SF_ CA1.l t209) 953-7691 <br />DEPARTMENT USE ONLY <br />// ��� Employee cv <br />Application Accepted By L � Date 3 Area ee ID# p y <br />Grout Inspection By Date 3 (o LL ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS�/ewie 'io bE, uzie_ I cneoi)r4Pred <br />t%1 <br />P <br />D <br />0 <br />a <br />N <br />T <br />�E93- <br />M, Cash <br />Service ��.. .. s <br />LIM <br />W,ZWO ' _ / � <br />II 1'7��1� IM854 <br />DD00-M 142SIM par t e(+ wd r1n wftn R <br />