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I WELL/PUMP PERMIT 1584 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95206 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 12091963-7697 FOR INSPECTIONS EXP <br />— IRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5419 S Stanley Rd _ CITY/ZIP Stockton/1584 <br />CROSS STREET. HWY 4 APN 187-06-012PARCEL SIZE�4 LAND USE APPLICATION # <br />OWNER NAME Tony Chiappe - Chiappe Farms PHONE 209-471-5791 <br />OWNER ADDRESS SAME CITY/STATE/ZIP <br />CONTRACTOR Delta Pump Inc PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St CITY/STATE/ZIP-Stockton/95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP <br />i <br />LICENSE _ L; C-57 X C-61 .7 D-09 11 Other NUMBER 1055434 EXPIRATION DATE 7131/202.3 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibrornochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 17 Domestic/Private L Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />1.1 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 Wells) # of wells ❑ Soil Boring(s) 0 of bonngs ❑Geotechnical � LS <br />H <br />Fl Out -Of -Service Well ❑ Out -Of -Service Well Renewal CCross-Connection <br />Repair wC <br />❑ New Pump X Pump Replacement '1 Pump Repair <br />❑ Raise Well Casing`Q <br />WELL CONSTRUCTION <br />Sq <br />Drilling Method ❑ Mud Rotary l -I Air Rotary J Auger f i Cable Tool n Push Point ❑ Other At <br />Proposed Well Depth ft Excavation in diameter E Open Bottom F, Gravel Pack/Gravel y O� �y`�emeter <br />Conductor <br />CI Casing in diameter / Conductor Casing Depth ft A �Tq/yTY <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel = Plastic ❑ Stainless Steel ❑ Other MF__ <br />Grout Seal Depth ft ;_1 Neat Cement (94 /b bag/5-10 gal water) C Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />iGrout Placement Method n Pumped ❑ Free Fall n Other C Retardant /Accelerator (name) <br />PEDESTAL Installed By 11 Driller ❑ Pump Contractor 11 Other <br />rI Concrete Pedestal IJ Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box I1 Stove Pipe <br />PUMP X Submersible❑ Turbine ❑ Other HP __5_ Pump Set 164 ft Standing Water Level _4Q_ ft <br />Plot Plan Requirements: Attach a plot plan with the: exact location of water well with respect to the following item.: (,PC <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 />MIN't1lf'NI 24 ift)[ \0 YI('I. Hi:(;i 1111,1) 1 L1fi 7�' (; Sfi�:°;. 1'i !'._i ,i / Ai-1.12t�`il' <br />DEPARTMENT USE ONLY <br />Application Accepted By ��,�� Date 3 d -,-dao Area �/ Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />�1 <br />Pump Inspection By Date Z0 _-z_ ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />' <br />COMMENTS i�l ti C'013 V) &,L -L, _ <br />PE <br />SC Received <br />Che <br />Amount Permit/ <br />Da <br />Codes <br />Info B <br />ash <br />--- <br />Remitted ServiceRe uest # <br />Invoice # <br />Well ID# <br />381 <br />Oso <br />-- 7 <br />7 WD WE Ic 0 0 473 <br />0/25/2021 Page 1 01, 2 Well / Pump Pwmii <br />N <br />m <br />D <br />°o <br />m <br />m <br />ih <br />