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l WELL/PUMP PERMIT 2554 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL ZUy 9bJ-/by/ FOR INSPECTIONS IZArIKtb l TEAR FROM DATE ISSUED <br />JOB ADDRESS 11450 N. Alpine Rd. clrY/zIP Stockton/95212 <br />CROSS STREET Bear Creek Rd. APN 063-050-50 PARCEL SIZE 4.35 LAND USE APPLICATION # <br />OWNER NAME Richard Cook PHONE 209-329-6053 <br />OWNER ADDRESS Same as Above CITY/STATEIZIP <br />CONTRACTOR Delta Pump Inc PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S California St CITY/STATEIZIP Stockton/95203 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 X C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE X Domestic/Private I rrigation/Ag ricultura I 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 OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -0f -Service Well Renewal Cross -Connection Repair <br />Ale.., D.. Y D-, D -1--t P.— P Rica W.11 r:acinn <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation 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 tA,,YMEN <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack m <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other t"N JOAOUIN COUN <br />Concrete Pedestal Dimensions: Width ft Length ft Thick HEALTH DEPaarME <br />in Christy Box Stove Pipe <br />PUMP X Submersible Turbine Other HP 3 Pump Set 120 ft Standing Water Level 80 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 Nvells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial "ell, provide location of any water wells or surface water within 200' radius of proposed well. <br />Uh"i 0I %I 1 114.1 1: - <br />/ DEPARTMENT USE ONLY <br />Application Accepted By —� 1 L— Date .747 a Area 1 Employee ID# <br />Grout Inspection By A Date _ ❑ SPECIAL Well Permit <br />Pump Inspection By Date ZZ ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />F HrxLf ;_an 10 25 2021 Ps< 1,42 W01 N P P<n„w -'o <br />