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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 GALL (209) 953-1691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 4850 S State Route 99 E Fr Rd & 3498 Metro Dr CITY/ZIP Stockton/95215 <br />CROSS STREET Arch Road <br />OWNER NAME Jivtesh Gill <br />OWNER ADDRESS P.O. BOX 235927 <br />CONTRACTOR West Coast Exploration Inc <br />CONTRACTOR ADDRESS P.O. Box 133 <br />SUBCONTRACTOR CTE CAL Inc <br />SUBCONTRACTOR ADDRESS 4230 Kiernan Ave Ste 150 <br />APN 17948-011 & 179-48-005 PARCEL SIZE ' 79 Acres LAND USE APPLICATION # <br />PHONE E 760-652-4010 Ext 104 <br />CITY/STATE/ZIP Encinatas/CA/92023 <br />LICENSE x C-57 C-61 D-09 Other <br />PHONE 209-985-7541 <br />CITY/STATE/ZIP Escalon/CA/95320 <br />PHONE 209-543-1799 <br />CITY/STATE/ZIP Modesto/CA/95356 <br />NUMBER 870761 EXPIRATION DATE 01/31/2024 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x 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 />Amount DatePermltl Invoice # Well ID# <br />Remitted S rv'ce ReJOSO <br /># of borings x Geotechnical 4 <br />Monitoring Well(s) # of wells Soil Boring(s) <br /># of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />pit 1' <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />, <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well <br />Depth 5, 10 ,15, 25 ft Excavation 4 in diameter Open Bottom Gravel Pack/Gravel Sizet <br />S1. <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />O q QV <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel <br />Oth�yFEV� <br />Grout Seal <br />Depth ft x Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />sack <br />Bentonite (20% solids) Other <br />R T <br />Grout Placement Method Pumped x Free Fall Other Retardant / Accelerator (name) <br />_ <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />�in 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By L Date <br />Grout Inspection By Date <br />Pump Inspection By 44 4Date <br />Soil Boring Inspection By Date TiZ <br />COMMENTS <br />Area Employee ID# A G <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />'/V Ty <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Ca h <br />Amount DatePermltl Invoice # Well ID# <br />Remitted S rv'ce ReJOSO <br />ERD043-06 1025/2021Page I of 2 Well / Pump Permit <br />a/I _-;�/�/07I/57 <br />