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ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel <br />Grout Seal Depth 4 s--96 ft / Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement <br />Bentonite (20% solids) 0 Other <br />Conductor Casing in diameter / Conductor Casing Depth <br /> <br />1 WELL/PUMP 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 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR COTTON, SHIRES AND ASSOCIATES, INC. <br />647 W Lindsay St <br />CALIFORNIA WATER SERVICE <br />1720 N. 1st St <br />cirdzip Stockton, 95203 <br />LAND USE APPLICATION # <br />PHONE (408) 318-8922 <br />CROSS STREET N Edison St <br /> <br />APN 13725003 <br />PARCEL SIZE I sa <br />CITY/STATE/ZIP San Jose, CA 95112 <br />PHONE 408-502-0401 <br />CONTRACTOR ADDRESS 330 Village Ln CITY/STATE/ZIP Los Gatos, CA 95030 <br />SUBCONTRACTOR WEST COAST EXPLORATION, INC PHONE 209-985-7541 <br />SUBCONTRACTOR ADDRESS P.O. BOX 133 CITY/STATE/ZIP Escalon, CA 95320 <br /> <br />LICENSE gi C-57 0 C-61 C D-09 0 Other NUMBER 870761 EXPIRATION DATE 0/ - 3 I - 2.021-4. <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE <br /> <br />0 Domestic/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring <br />Public Water System <br />If different from Owner Water System Name <br />g Soil Sampling/Characterization <br /> <br />Contact Name or Phone Number <br />TYPE OF WORK 0 New Well D Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump D Pump Replacement <br />0 Well Alteration/Modification 0 Other <br />Li Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair <br />PA 1. <br />C6../ • <br />0 Cross-Connection Repair <br />0 Raise Well Casing <br />Geotechnical 2 # of boring <br />P :SS3):10CIV 3119 S • • NAR 30 <br /> 2022 <br />C Allti 0 Other tHcr bizPAI <br />sack mix/7 gal %Yam <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br /> <br />0 Retardant / Accelerator (name) <br /> <br />PEDESTAL Installed By E Driller 0 Pump Contractor 0 Other <br /> <br />Concrete Pedestal 0 Dimensions: Width ft Length <br />in D Christy Box 0 Stove Pipe <br /> <br />ft Thick <br /> <br />PUMP TI Submersible El Turbine El Other HP <br /> <br />Pump Set ft Standing Water Level <br /> <br />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 />\ it NI 14 Hui II 0 )\ \(4114 I la ot IIflI ,1,011 1 \NFL( i .‘1,1,209 )9-ij <br />DEPARTMENT USE ONLY <br />Application Accepted By Date V20,42.)- Area I/ SI-De/40n Employee ID# S <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Ispection By SO ,' Date Y/Y/CL- Constructed Well Depth , ft ., 4 <br />COMMENTS 71e/11/ e ppe. -to be a _ler/ ir ufeefer thcari 0 feei- or ; l' 5r °" eiviC41.6 )--- ) e n coy I fel-ea <br />PE <br />Codes <br />SC <br />Info <br />Received 2 Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />4 -7 3g isz) <br />7 a eiGeJ i -V- *o(5. 40110 tA*101-11Al <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary D Air Rotary Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth 25-40 ft Excavation 4 <br /> <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br /> <br />A i6meter <br />DuN,. <br />1/E-Air <br />SPECIAL Well Permit <br />WAIVER Received <br />51-10043-06 10/25/2021 <br />6pti <br />Page 1 o12 Well / Pump Permit <br />