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I 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/I55UtL <br />JOB ADDRESS 11-39) A i ryyeiL1,., y (J CITYIZIP A 4t V, `Le C L1 q S-'3`-7 6 — <br />CROSS STREET R o } i RA— APN ��� Ci O O I PARCEL SIZE 3 1 ' E' LAND USE APPLICATION # <br />OWNER NAME lAawi oie% f2aG ittL JEcf; 1r0clitcl (attn: David Nielsen) PHONE (402) 544-3330 <br />OWNER ADDRESS 1400 Douglas Street CrrY/STATE21P Omaha NE 68179-0910 <br />eer14RAsTeR CONSULTANT Shannon & Wilson, Inc. (attn: Steve Diem) PHONE (818) 539-8418) <br />Ge*TRAeiARADDRESS 100 N 1st Street, Suite 200 CITY/STATE/ZIP Burbank, CA 91502 -7 <br />SUBCONTRACTOR I c a e T O✓ I 1 h PHONE 1I / L <br />SUBCONTRACTOR ADDRESS SIO!6:754 I V'C_"� 61 -1 CITY/STATEfZIP Wi G <br />LICENSE IN C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 969927 ExPIRATION DATE 02.29.2024 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Yfoll 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells _ i r # of borings Geotechnical A of borip <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair R M <br />Ll New Pump ❑ Pump Replacement ❑ Pump Repair 0 Raise Well Casing A 76�r <br />DA <br />Drilling Method Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other 4 <br />L9f Lqr/T F <br />Proposed Well Depth S = 5y ft E-cavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizeS In die <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft EQ(//N <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic 0 Stainless Steel ❑ Ot Ld O <br />Grout Seal Depth - 5 T) ft p( Neat Cement (94 /b bagi5-10 gal water) ❑ Sand Cement sack77m <br />0 Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 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 />MININIUM 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />y� l DEPARTMENT,) USE ONLY <br />Application Accepted By �f� — Date 7 / 1 ''7'` <br />L <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />AreaG �� <br />Employee tD# — <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Date Constructed Well Depth <br />PE Sc Received Check#/ Amount Permit)Codes I Info 13N, Cash Remitted Date Service Re uest# Invoice# WeIIID# <br />o 3k ' 1 I :22 I SLI <br />rED043-06 102512021 Page I ort <br />Well / Punp Pernut <br />ft <br />�r <br />0 <br />