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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 808 Zephyr St CITY/ZIP Stockton,CA 95206 m <br /> .1 D <br /> CROSS STREET Perlman Dove la)�F'Df T �N 1772806 Q PARCEL SIZE �1 q�LAND USE APPLICATION# 0 <br /> h(`��-1 LLC <br /> ' m <br /> OWNER NAME Chrisp Company-Robert Chrisp /6U7.7- �/�1l�es LLC PHONE 510-656-2840 y <br /> OWNER ADDRESS 1805 E.Beamer Street CITY/STATE/ZIP Woodland,CA 95776 <br /> CONTRACTOR Gularte and Associates,Inc. PHONE 916-626-5577 <br /> CONTRACTOR ADDRESS 1049 Nichols Drive CITY/STATE/ZIP Rocklin,CA 95765 <br /> SUBCONTRACTOR Cal-Nev Geo Exploration PHONE 916-778-0089 <br /> SUBCONTRACTOR ADDRESS 1079 Sunrise Avenue,Suite B-339 CITYISTATEIZIP Roseville,CA 95661 <br /> LICENSE ® C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1039188 EXPIRATION DATE 5/31/2024 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N 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 R Geotechnical_3 ofboy <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 4� <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing1 <br /> WELL CONSTRUCTION R4 2A O <br /> Drilling Method Ll Mud Rotary ❑ Air Rotary fl Auger ❑ Cable Tool ❑ Push Point ❑ Other ,�/ <br /> Proposed Well Depth 25 ft Excavation 4 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size N in A <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft /yF"v V//?"°ON <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 11Plastic ❑ Stainless Steel ❑ Othel��/ ONMFCpU <br /> Grout Seal Depth 25 ft p Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix P r <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall El Other Trimie ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimensions: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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ��liL Date say �a Area I 5tOck'drr Employee lD# A- <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By to -, WAIVER Received <br /> Soil Boring Inspection By 7z <br /> c Date 'Z ZZ Constructed Well Depth ft <br /> COMMENTS <br /> ---- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> LI 3742 SO SQ_ 76 O '► <br /> F--I <br /> EHD043-06 04/07/2022 � ^ n Page I of 2 Well/Pump Permit <br />