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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 /> Ln <br /> JOB ADDRESS 808 Zephyr Sl CITY/ZIP Stockton,CA 95206 m CROSS STREET Perlman Drive I�pD�} APN 1772806 0 PARCEL SIZE �t LAND USE APPLICATION# A <br /> OWNER NAME Chrisp Company-Robert Chrisp / Q UZZ 04 lei <br /> es L—L-C PHONE 510-656-2840 y <br /> N <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 CITY/STATE/ZIP Roseville,CA 95661 <br /> LICENSE k] C-57 ❑ C-61 n D-09 ❑ Other NUMBER 1039188 EXPIRATION DATE 5/31/2024 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteda(4391) Dibromochloropropane(4392)I Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 Or WORK New Well J Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of honngs xGeotechnical_3 #,,f boIlDhse <br /> i i Out-Of-Service Well LI Out-Of-Service Well Renewal 7 Cross-Connection Repair <br /> C New Pum ❑ Pum Replacement [I Pump Repair 7 Raise Well Casing ��C 11 T <br /> WELL CONSTRUCTION qi4 O <br /> Drilling Method C Mud Rotary ❑ Air Rotary z] Auger Cable Tool L1 Push Point ❑ Other ��/ <br /> Proposed Well Depth 25 ft Excavation 4 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size // in dia <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft NE" ✓lI� `LIN <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic L Stainless Steel _ OtheTN ON��1FP 0( y <br /> Grout Seal Depth 25 ft Q Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mixl tdiP r <br /> G Bentonite(20%solids) C Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 19 Other Trimie L Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller C Pump Contractor C Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box 0 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 /> MININIUN124 HOUR ADVANCE NO ICE REQUIRED FOR 1\SPEC-(IONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By — liL Date s aV/5 02 Area IStockl� Employee ID# A- <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection Ry ate El WAIVER Received <br /> / <br /> Soil Boring Inspection By ( " Date �2 Constructed Well Depth ft <br /> COMMENTS v <br /> PE SC Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 37 aS O SQ_ 760 ,r <br /> f11DW3-06 04/07/2022 �^ n P"gc I or' 0.'all/Pwtyi Pcrrnit <br />