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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL ZUy yb3-tbUt FOR INSPECTIONS tAI'IKtb 'I YEAR FROM L1ATE ISSUED <br />JOB ADDRESS 795 Brovelli Woods Ln CITY/ZIP Acampo, 95220 <br />CROSS STREET Sequa Rd APN 00310040 <br />OWNER NAME Brovelli Wood LLC <br />OWNER ADDRESS 2820 W Forest lake Dr <br />CONTRACTOR Neil 0. Anderson: a Terracon Consultants Company <br />CONTRACTOR ADDRESS 902 Industrial Way <br />SUBCONTRACTOR Same <br />SUBCONTRACTOR ADDRESS Same <br />LICENSE ® C-57 ❑ C-61 ❑ D-09 ❑ Other <br />SIZE 21.08 LAND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP Acampo, 955220 <br />PHONE (209) 367-3701 <br />CITY/STATE/ZIP Lodi, Ca 95240 <br />PHONE Same <br />CITY/STATE/ZIP Same <br />NUMBER 669004 EXPIRATION DATE 5/31/2023 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (439 1) ❑ Dibromochloropropane (4392) 0 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 N Geotechnical 3 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rotary n Air Rotary N Auger ❑ Cable Tool ❑ Push Point n Other <br />Proposed Well Depth 20 ft Excavation 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 20 ft N Neat Cement (94 /b bag6-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) U Other <br />Grout Placement Method ❑ Pumped N Free Fall ❑ Other 0 Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level It <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 IIOUR ADVANCE NO'IICE REQUIRLD FOR INSPEC4 IONS - PLEASE CALL (209) 953-7697 <br />PARTMENT USE ONLY <br />s 7 A <br />Application Accepted By v Date Area Employee ID <br />4a - <br />Grout Inspection B Date ❑ SPECIAL Well Permit 0% <br />Pump Inspection By 4 Date ❑ WAIVER Received®� <br />Soil Boring Inspection By ` Date Constructed Well Depth F ft <br />COMMENTS AN./n. _ / <br />PE SC Received <br />Codes Info B <br />Chec Amount D to Permit/ Invoice #� <br />Cash Remitted Service Request # <br />220E <br />EHD043-06 1025/2021 Page I or 2 Well/ Pump Permit <br />