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4 <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT CALL 2U9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS _ p 3 (Kasson Road) CITY/ZIP Tracy 9 S 3 j) L -I <br />T <br />CROSS STREET y• r� j APN 23909004 PARCEL SIZEUL LAND USE APPLICATION /# <br />OWNER NAME PA C I �7 � 64ts 41111c) E l e c itr i c PHONE J <br />OWNER ADDRESS PO Igo)( /-70000 CITY/STATE/ZIP <Q F1 F fC?n C. i's e.a t7 I/- <br />CONTRACTOR Far Western Anthropological PHONE 530-756-3941 <br />CONTRACTOR ADDRESS 2727 Del Rio Place CITY/STATE/ZIP Davis, CA 95618 <br />SUBCONTRACTOR Confluence Technical Services, Inc. <br />SUBCONTRACTOR ADDRESS 6821 8th Street <br />LICENSE rx C-57 C C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER 1035255 <br />PHONE (916)760-7641 <br />Rio Linda, CA 95673 <br />EXPIRATION DATE 01/31/2024 <br />DOMESTIC WELL SAMPLING: L_ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Inigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X 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 />0 Monitoring Well(s) # of wells X Soil Boring(s) 3 # of borings ❑ Geotechnical <br />0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Bl Push Point ❑ Other <br />Proposed Well Depth 30 ft Excavation 4 inches in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ElPlastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth 30 ft N Neat Cement (94 Ib bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 9 Free Fall N Other Tremie Pipe ❑ Retardant / Accelerator (name) <br />3EDESTAL Installed By 7 Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />n ❑ 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 - L� Date 7 .� <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By ,� .s'Ff1'^ Date <br />COMMENTS <br />Area �� /f Employee ID# <br />❑ SPECIAL Well Permit <br />-1 WAIVER Received <br />Constructed Well Depth ft <br />T <br />1 <br />m <br />0 <br />O <br />m <br />m <br />m <br />ur <br />PE <br />Codes <br />SC Received <br />Info Bv <br />Check#/ <br />Cash <br />Amount to <br />Remitted I <br />Permit/ Inv # eIIID# <br />Service Request # <br />? <br />JOAQU <br />HE�i NME UIVTY <br />AE <br />EHDO43-06 04/07/2022 /t w - f ; I -� / - 20MI /' Page I of 2 Well / Pump Permit <br />