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l 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 ISSUED <br />IDB ADDRESS Yr CITY/ZIP Thonron, CA/95686 <br />CROSS STREET b (�c.1I't'Si'' �+ ' APN 00111039 PARCEL SIZE6iel/LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />Crawford & Associates, Inc. <br />CONTRACTOR ADDRESS 1100 Corporate Way, Suite 230 <br />SUBCONTRACTOR GeoEx Subsurface Exploration <br />SUBCONTRACTOR ADDRESS 704 Norh Adams Street <br />(K PHONE <br />CITY/STATE/ZIR! jJ1_4_(1 J <br />PHONE 775-762-3315 <br />CITY/STATE/ZIP Sacramento, CA/95831 <br />PHONE 916-835-0714 <br />CITY/STATE/ZIP Dixon, CA/ 95620 <br />LICENSE ['1 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 954267 EXPIRATION DATE 07/31/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) H Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring 6( 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other.__ <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 9 Geotechnical 2 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br />Drilling Method fXMud Rotary ❑ Air Rotary � Auger ❑ Cable Tool ❑ Push Point ❑ Other__ <br />Proposed Well Depth 5-50 ft Excavation 4-6" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size_ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other__ <br />Grout Seal Depth 5-50 ft 19 Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) D Other _ <br />Grout Placement Method Bl Pumped X Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other RECEIVED <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 �e?lL OUNTY ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the If€illbWiliff'r €Fins: 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 />DEPARTMENT USE ONLY <br />Application Accepted By r% �- i % Date 7 7 % / i 3 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 7 / Employee ID#I- <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />to <br />PE <br />Codes <br />SC Received Check#/ <br />Info By Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />3 7,2 <br />4 C�- <br />FHD043-06 04/07/2022 Page I or2 Well / Hmip Permit <br />