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1 WELUPUMP PERMIT <br /> SAN JOAOu1N CODNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> CD <br /> Joe ADDRESS 7761 W. Undine Road CTy0p Stockton, CA 95206 <br /> D <br /> CROSS STREET Howard Road APN 189.200-066 PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME BL xler Ranch PHONE (209) 462-0208 <br /> OWNER ADDRESS 7-761 titi . Undine Road CITYISTATEMP S r O c k r o I l r CA 95206 <br /> CONTRACTOR BSK Associates PHONE (209) 769-4734 <br /> CONTRACTOR ADDRESS 550 W Locust Avenue CITYISTATE/LP Fresno, CA, 93650 <br /> SUBCONTRACTOR BSK Associates PHONE (209) 769-4734 <br /> SUBCONTRACTORADOREss 550 W Locust Avenue CnvISTATE/Z,P Fresno, CA, 93650 <br /> LICENSE X C-57 n C-61 n D-09 n Other NUMBER 490942 EXPIRATION DATE 12/31/2022 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE n Domestic/Private 0 IrrigationtAgricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> ff dlerent from Owner: Water System Name Conran Name or Prone Number <br /> TYPE OF WORK n New Well 0 Replacement Well C Well Alferation/Modification :i Other <br /> I Monitoring"I(s) A of wells u Soil Boring(s) 'r d bow X Geotechnical 4x10' °of bonne' <br /> n Out-Of-Service Well 0 Out-Of-Service Well Renewal L;Cross-Connection Repair <br /> U New Pump t I Pump Replacement o Pump Repair o Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary 0 Auger :_Cable Tool I I Push Point X Other hand auger borings <br /> Proposed Well Depth 10 it Excavation 4" in diameter 0 Open Bottom I-]Gravel Pack/Gravel Size in diarp@ter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth R A <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad u Steel a Plastic c Stainless Steel n Other <br /> Grout Seal Depth fl R Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mixf7 gal <br /> n Bentonite(20%solids) 0 Other `O <br /> Grout Placement Method 0 Pumped H Free Fall 0 Other u Retardant/Accelerator(name) 9 <br /> PEDESTAL Installed By n Driller 0 Pump Contractor Other Jr) `O?2 <br /> n Concrete Pedestal ODlmensions:Width It Length It Thick <br /> lin E Christy Box 0 Stove Pipe O(J/v <br /> PUMP Submerslble0 Turbine 0 Other HP Pump Set tt Standing Water Level ft MENTI <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 /> �11NI.%tt;Nl 24 ROUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Ly J3/2.2 Area Employee IDA <br /> Application Accepted By �� Date �/ <br /> Grout Inspection By Date 2 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Checkk9l Amount a Pertnw Invoice A Well IDA <br /> Codes Info B =, h Remitted Service R uest A <br /> 37a <br /> ElID043-06 ID12VMZ I Page I erg Wcg r Pump hrmzt <br /> 1�gZ 9s�/ <br />