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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDABLE PERMIT GALL ZUy y93 -/by/ FOR INSPECTIONS LAPIKL5 7 YEAR FROM DATE ISSUED JOBADDRESS Grant Line RoadCITY/ZIP�Trac 95304 ---------------------------------- -------------------------- -- N Chrisman Road 2130 9 n3o-ror }'- � II,`l LA CROSS STREET_—__—___—_—__—_ APN �,�Rn�avl PARCEL SIZ2�ND USE APPLICATION #____—__—__—_ OWNER NAME _See -fried Industrall_Propertles,_Inc=Sean Sheppard_______ PHONE_ 480_492-0120_—_ OWNERADDRESS 2^2'01 E_Camelback_Road, Suite222CITY/STATE/ZIP__P hemi. AZ$5Qj_6__—__ CONTRACTOR �LyOEv r�lcornQr�y�si-- -- ------ --------------- PHONE _925_719 -0822 -------- CONTRACTOR ADDRESS -1,�7/2+78 Golden Valley ParkwayCITY/STATE/ZIP__LathrgpL CA -95330 _ SUBCONTRACTOR _yYQ1J �Q�St EXplpJatlon _ _ PHONE 209_985_7541 SUBCONTRACTOR ADDRESS _P_O_Box _1-33 —__ CITY/STATE/ZIP__EcalQD,QA-9532Q_—__—___—_ LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other-- --- NUMBER _870761 EXPIRATION DATE—_1 /31 /2024 _—_ DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) C Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s)—__—__ # of wells ❑ Soil Boring(s) ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa # of borings X Geotechnical _-4—__# of borings 1 ❑ Cross -Connection Repair WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth__1G_4_G__ft Excavation _-4___— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size ❑ Conductor Casing ---- —__ in diameter / Conductor Casing Depth in diameter Well Casing Diameter ____ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel 0 Other -_—__ Grout Seal Depth__ 10-40 _ ft X Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement --- ----- __----- sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall X Other Tremie ❑ Retardant / Accelerator (name) __—__—_�AUAWhff--- —__ PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing WatemNe w ft Enly' ]It Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the follaeownems: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NO'T'ICE REQUIRED FOR 1NSPE( (IONS - PLEASE CAIA, (209) 9.53-7697 - DEPARTMENT USE ONLY Application Accepted By _ � _ Date _-911 16 eR__—_ Grout Inspection By Date Pump Inspection By __ Date Soil Boring Inspection By — —__— Date COMMENTS Area_S1_q� Employee ID#_ A�__ ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft T M-4 0 0 X w H PE Codes SC Received Check#/ Info Cash Amount emitted Date Permit/ ice Request # Invoice # Well ID# 7.2 IS -0 f eq34 12 E DO43-06 04/072022 Page 1 of 2 Well / Pump Permit