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1 WELL/PUMP PERMIT 2121 SAN JOAOUIN COUNTY ENVIRONMENTAi 1464»' DEPAkTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS �� n d.. 1��5�I- "f�� i 1 cITY/LP Stockton/95215 CROSS STREET JCY+Ww60_d L-'DPr � f : _ APN LUd�3-UU4 �� tT PARCEL SIZE 154.21 LAND USE APPLICATION # OWNER NAME G&G Ranch i4 ILL - Contact Rob Norman PHONE 209-479-4661 OWNER ADDRESS 13801 Wildwood Rtl: CITYISTATE/ZIP Stockton/95203 ADDRESS 646 S. CA ifibrnia St. CITY/STATE/7JP_S1QQ0M1952W PHONE ADDRESS LICENSE 0 C-57 X C-61 ❑ D-09 ❑ Other CITYISTATE/Z1P NUMBER 1055434 EXPIRATION DATE 7/31/2023 DOMESTIC WELLSAMPUNG: ❑ General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) INTENDED USE 0 Dcmeslic/Private Irrigation/Agdcultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charactedzatlon ❑ Public Water System . If dlfforont from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other ❑ Monitoring Well(s) # of wells 0 Soil Boring(s) a of borings 0 Geotechnical 0 of boringsp 0 Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair Yl 0 New Pump 0 Pump Replacement Y Pump Repair ❑ Raise Well Casino 1 ��' C Drilling Method D Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool 0 Push Point ❑ Other 4PR f ., Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Sized In diam r ❑ Conductor Casing in diameter / Conductor Casing Depth ft lhI//AQP/N Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 0 Steel ❑ Plastic ❑ Stainless Steel 0 0644 RO C, Grout Seal Depth_ft ft ❑ Neat Cement (94 Ib ba9/5-10 gat water) 0 Sand Cement sack mut ❑ Bentonite (20% solids) 0 Other Grout Placement Method D Pumped ❑ Free Fall D Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other ❑ Concrete Pedestal ODlmenslons: Width It Length it Thick in 0 Christy Box ❑ Stove Pipe MP ❑ Submersibig Turbine ❑ Other HP -50-- Pump Set 140 ft Standing Water Level 88 ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS 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. MININ'IUM 24 HOUR ADVANCE, NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY Application Accepted By L�— Date �. / � ✓ � Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date Z:> Sum VK)2-'Z ❑ WAIVER Received Sol[ Boring Ins ion By Date Con tructe Well Depth ft COMMENTS �1 `�w �+\ O \l\�'C,i 1 V\�ROQ Gi LI �aa -.4i"& 7e_e r,7f_t l' k EHDW3-06 10/2312021 Page I of 2 Well / Pump Permit 'iAliiiiiiiiii •. ServiceeRequest IF%2eJW.s r E�611ffi I►A . . EHDW3-06 10/2312021 Page I of 2 Well / Pump Permit