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1 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 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS 7/01 L l' (= r Rd Cm/Zip Gc, I t , CA 9 S'6 s;2 <br />CROSS STREET-Dusli n Road APN 005-230-050 PARCEL SIZE 7 Cr r 3 LAND USE APPLICATION # <br />DINNER NAME Rebecca Seifert <br />PHONE <br />OWNERADDRESs 8505 Collier Road E <br />CONTRACTOR BSK Associates <br />CONTRACTOR ADDRESS 550 W Locust Avenue <br />CITY/STATE/ZIP Acampo, CA 95220 <br />PHONE 209 769-4734 <br />CITY/SrATE/ZIP Fresno, CA, 93650 <br />SUBCONTRACTOR BSK Associates PHONE (209) 769-4734 <br />SUBCONTRACTOR ADDRESS 550 W Locust Avenue CITYISTATE/ZIP Fresno, CA, 93650 <br />-ICENSE X C-57 ❑ C-61 ❑ D-09 1 Other. <br />NUMBER 490942 EXPIRATION DATE 12/31/202D <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED U$e ❑ Domestic/Private ❑ Irrigation/Agricultural n Industrial 17 Water Quality Monitoring 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 Replacement Well i Well Alteration/Modification ❑ Other <br />t_i Monitoring Well(s) # of wells 1 Soil Borings) # of borings X Geotechnical 2:.. _ # or borings <br />Out -Of -Service Well 'I Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Pum _-, Pump Replacement ' Pump Repair Raise wolf r—.... <br />WELL CONSTRUCTION <br />,�6q/VED <br />APR 0 <br />Drilling Method L Mud Rotary Air Rotary ❑ Auger n Cable Tool Push Point Hand Auger Boring sgN�gQult <br />„- p � Other <br />Proposed Well Depth 10 ft Excavation 4 in diameter i Open Bottom i Gravel Pack/Gravel Size illa��eh <br />C Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad C; Steel I : Plastic ❑ Stainless Steel F Other <br />Grout Seal Depth-10—ft X Neat Cement (94 lb bag/5-10 gal water) I Sand Cement sack mW7 gal water <br />Bentonite (20% solids) ,- Other <br />Grout Placement Method 1. Pumped X Free Fall C Other Rararrinnt r A—lerat.,r r„-% <br />PEDESTAL Installed By -i Driller 11 Pump Contractor <br />7 Concrete Pedestal (.!Dimensions: Width It <br />in U Christy Box n Stove PIDS <br />Other <br />Length <br />ft Thick <br />PUMP U Submersible:, Turbine "1 Other HP Pump Set ft Standing Water Level ft <br />Piot 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />011111111111 <br />DEPARTMENT USE ONLY <br />Application Accepted By t1 Date % Area / Employee ID#� <br />Grout Inspection By �.�c,'S co m k ;:71 _ Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring inspection By Date Constructed Well Depth ft <br />COMMENTS nA� / 914 Nr,da 1--i", f� <br />2022 <br />NTA <br />T41ENT <br />Puge I ort <br />Well / Pump Permit <br />