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1 j d 7 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 ZUy blbJ-fli FOR INSPECTIONS rArlttCJ 7 Tt_AK FKL)Vi LJAIt IJJUtU <br />JOB ADDRESS I5 a I r 0 r 1 CfTY1ZIP 1 <br />CROSS STREETAAbb 41`14 L� I � � t�� � � �o PARCEL SIZE I��LAND USE APPLICATION # <br />OWNER NAME Diamond Galaxy Partners LLC PHONE 925-674-8400 <br />OWNER ADDRESS 1200 Concord Ave., Suite 200 CITYISTATE/ZIP Concord. CA 94520 <br />4�2s-c{g�{- b22o <br />CONTRACTOR P <br />S HONgE <br />CONTRACTOR ADDRESS C CITY/STATE/ZIP 1FuasQadh <br />SUBCONTRACTOR Ill a(rt!' 'Xl r,i it,, (, e`(V _ PHONEE025/) �3�13-5800 <br />SUBCONTRACTOR ADDRESS U / CITYIISITATEIZIP t-Uhhl�e "L, CA 01 <br />C - <br />LICENSE 57 ❑ C-61 ❑ 0-09 D Other NUMBER 1 O T4 1S -Lo EXPIRATION DATE 09/30/2022 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE. 0 Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) #of borings eotechnical ID of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Goss Co vection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotaryuger ❑Cable Tool ❑Push Point x Other <br />Proposed Well Depth IG - ;jJ 1l Excavation _ in diameter ❑ Open Bolcom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter I Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic O Stainless Steel ❑ Other <br />Grout Seal Depth ;J i J L ft ,$ Neat Cement (94 1b bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 0 Free Fall 0 Other ❑ Retardant I Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other PAYMtNII <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in O Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersibleu Turbine ❑ Other HP Pump Set ft Standing Water Level IANI I OuI <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />UIN <br />OUI <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, �I'(A <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. Fom#a9iHE TM1 <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 />DEPARTMENT USE ONLY m <br />Z— /, ���e���J!t— Area /►�! �F((. �f <br />Application Accepted B Date '� Employee ID# <br />Grout Inspection By `3 �,� a Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVERReceived <br />Soil Boring Inspection By Date Constructed Well Depth _ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Da <br />bash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request# <br />EHD043-0610/2512021 Pae, 1 ort <br />(..� 136og31° <br />2-1 <br />W,II I Pump Po mit <br />