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r <br />1 WELL/PUMP PERMIT <br />S,;N .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS 7119 E Mariposa Rd <br />GALL <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton 95215 <br />Austin Rd 17M2-014, 181-04-021, 181-04023. <br />CROSS STREET APN 181-04-018, 181_04-003,181-04-002 <br />OWNER NAME BNSF Development Co., LLC <br />OWNER ADDRESS 2650 Lou Menk Drive <br />CONTRACTOR Neil O Anderson, A Terracon Company <br />CONTRACTOR ADDRESS 902 Industrial Way <br />SUBCONTRACTOR N/A <br />SUBCONTRACTOR ADDRESS N/A <br />LICENSE x C-57 C-61 i D-09 i i Other <br />ARCEL SIZE LAND USE APPLICATION # <br />PHONE 817-867-6845 <br />CITY/STATE/ZIP Fort Worth, Texas 76131 <br />PHONE 209-367-3701 <br />CITY/STATE/ZIP Lodi, CA 95240 <br />PHONE N/A <br />CITYISTATE/ZIP N/A <br />NUMBER 669004 EXPIRATION DATE 5/31/2023 <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 New Well I i Replacement Well I Well Alteration/Modification Other <br />Monitoring Well(s) # of wells 1 Soil Boring(s) # of borings x Geotechnical 10 # of borings <br />Out -Of -Service Well II Out -Of -Service Well Renewal I I Cross -Connection Repair <br />New rump rump Keplacemem -i rump Kepalr a Kaise vveu casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth 15 to 50 ft Excavation 4-6 in diameter I Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />in diameter <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic i Stainless Steel i Other <br />Grout Seal Depth IS- S`0 ft x Neat Cement (94 Ib bag15-10 gal water) I i Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall < Other 4/e w+I E Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller Pump Contractor Other <br />Concrete Pedestal iDimensions: Width ft Length ftThick <br />in i Christv Box I Stove Pioe <br />PUMP I Submersiblel . Turbine I Other HP Pump Set ft Standing Water Level ranl 4 ,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 w Ivi <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. L <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 />V1 <br />m <br />m <br />D <br />0 <br />O <br />A <br />y <br />IC <br />NTY <br />,y Cash <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />iV 11��­­Date 1 /3 <br />Area` Employee ID# a <br />Grout Inspection B Y <br />Date <br />El Well Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth ft <br />COMMENTSIfLoMIe Jo <br />be JF <br />aloUndVJ`Mir IS en, -0 '1tf1PC-1 <br />orL-JePDrr 000 30 (PB) - <br />V1 <br />m <br />m <br />D <br />0 <br />O <br />A <br />y <br />IC <br />NTY <br />END043-06 1025 2021 Page I of 2 Well , Pump Permit <br />NT <br />,y Cash <br />Remitted <br />__Ir <br />END043-06 1025 2021 Page I of 2 Well , Pump Permit <br />NT <br />