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1 :!�a a Li WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABiLE PERMIT GALL (LUV) `Jb3-1b`Vf FOR IN5PEGTIUNS CAr'IMMO l TEAR FRUM DATE 155UED JOBADDRESSS0'� IJt Main Street and South Walker Lane CITY/ZIP Stockton/95215 D e 1 Mar Avenue n3-280 025 ; -030; -010 1 CROSS STREET APN PARCEL SIZE 1 _LAND USE APPLICATION # OWNER NAME (Steve Lagomarsino; Robert A Caffese;Colombini Brothers, LLC.) PHONE 916-918-5}}541h �`0 CITY/STATE/ZIP d) 9� 1y PHONE 209-815-5440 OWNER ADDRESS b 9 b f Live C)eI< R cl CONTRACTOR Hillside Geotechnical Drilling CONTRACTOR ADDRESS PO BOX 143 CITY/STATE/ZIP Tracy/CA/95378 SUBCONTRACTOR Mid Pacific Engineering, INC. PHONE 916-927-95378 SUBCONTRACTOR ADDRESS 840 Embarcadero Dr. #20 CITY/STATE/ZIP West Sacramento/CA/95605 LICENSE X C-57 ❑ C-61 C D-09 ❑ Other NUMBER 800276 EXPIRATION DATE 06/30/2023 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural � 1 Industrial n Water Quality Monitoring y r Soil Sampling/Characterization CI Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK L New Well Li Replacement Well ❑ Well Alteration/Modification ❑ Other L Monitoring Well(s) # of wells X Soil Boring(s) 10 # of borings ❑ Geotechnical Li Out -Of -Service Well -1 Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New NumD LI ❑ Kalse WeII # of borings Drilling Method ❑ Mud Rotary ❑ Air Rotary A Auger I 1 Cable Tool ❑ Push Point I I Other Proposed Well Depth 10-15 ft Excavation 4.5 in diameter 5 Open Bottom l Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth 10-15 ft 9 Neat Cement (94 /b bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped K Free Fall ❑ Other -i Retardant / Accelerator (name) PEDESTAL Installed By -� Driller -I Pump Contractor ❑ Other Concrete Pedestal ;Dimensions: Width ft Length ft Thick n Christy Box Stove Pipe PUMP I Submersible❑ Turbine -I Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. %IININIt'NI 24 HOt R ADVANCE NOTICE: RE:Qt']RED FOR INSPECTIONS- PLEASE. CALL (209) 953-7697 DEPARTMENT USE ONLY 1 Application Accepted By ate 5 c� Area l Employee Grout Inspection By i / Dat ❑ SPECIAL Well Per Pump Inspection By Date ❑ WAIVER ReCelved,��`` Soil Boring Ins ection By Date Constructed Well Depth A COMMENTS �lMllQ Jai SI C tiiou'i^dV4riper, fS 'Pp')GOulliefed, 46A& T m D 0 0 A m N PE Codes SC Received Check#/ Info By Cash Amount Date Permit/ Invoice # �Fp Remitted rvice Re uest # y37d ASO VIy 22 NT BIID077-06 10;2�/202I 00+1 HO 8V��f 2 Wcll /Pump Pcrmn