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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 />JoB ADDRESS 22261 Mountain House Pkwy c,/ZIP Tracy, 95391 <br />CROSS STREET W. Grant Line Rd. APN 209-06-665 PARCEL SIZE IL40 LAND USE APPLICATION # <br />1 I �[ <br />OWNER NAME l'M't lOf O V C� I -�oGh rl e /I r LTJ I� ETA L PHONE �` y�(,� <br />OWNER ADDRESS ��� W� Granf LI�e A CITY/STATE/ZIP J )r4(,V �J 3y l <br />CONTRACTOR Technicon Engineering Services, Inc. PHONE 559-276-9311 <br />CONTRACTOR ADDRESS 4539 N. Brawley Ave. Suite 108 CITY/STATE/ZIP Fresno, CA 93722 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP o <br />LICENSE C-57 ❑ C-61 0 D-09 0 Other NUMBER 767888 EXPIRATION DATE a 31 An— <br />DOMESTIC <br />DOMESTIC WELL SAMPLING:: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392): : Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 9 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 0 Replacement Well 0 Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells R Soil Boring(s) # of borings Geotechnical 5 ofborings <br />❑ Out -Of -Service Well ❑ Out-Of-Servic Well Renewal 0 Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION �v <br />Drilling Method 0 Mud Rotary ❑ Air Rotary X Auger 0 Cable Tool ❑ Push Point ❑ Other Agp. <br />Proposed Well Depth 0-50' ft Excavation 4" in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel���,ilt_eter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft ✓0 Q 1 <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steely U/ <br />42 <br />Grout Seal Depth O -SO ft /Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement B� 4C4" <br />❑ Bentonite (20% solids) 0 Other ARS <br />Grout Placement Method 0 Pumped ❑ Free Fall 0 Other 0 Retardant / Accelerator (name) NT <br />PEDESTAL Installed By n Driller Pump Contractor ❑ Other <br />D Concrete Pedestal ❑Dimensions: Width ft Length ftThick <br />�in D 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 S a7 Z Area S -rirQ Employee ID# S <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />,,�� <br />Soil Boring Inspection By [ii,�� Date •i 1_ Constructed Well Depth ft <br />COMMENTS 'lrP,,.ie >oitoe be uSeGl �f oleene� ty►ar► s� 7 or r4lir 440' " Br►LOUYl 4erc <br />4. <br />EHDO43-06 04/07/2022 <br />Page I of 2 <br />Well / Pump Permit <br />a W—M <br />EHDO43-06 04/07/2022 <br />Page I of 2 <br />Well / Pump Permit <br />