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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 />IVUIV-KEFUNDABLE rERMIT L ALL (ZUU) <br />U04-1t)Ut FOR INSPECTIONS <br />tAll'IKtb I YEAR FROM UATE ISSUED <br />Joe ADDRESS <br />1140 S Vecindas street <br />CITY/ZIP <br />Mountain House/ CA 95391 <br />CROSS STREET <br />Olson Avenue APN 262-020-100-00 <br />PARCEL SIZE 0.99 Acre <br />LAND USE APPLICATION # <br />OWNER NAME <br />Giri Kairamkonda <br />PHONE <br />510-917-7327 <br />OWNER ADDRESS <br />1047 Walcott Avenue <br />CITY/STATE/ZIP <br />Mountain House/ CA / 95391 <br />CONTRACTOR _SALEM ENGINEERING GROUP, INC. PHONE (559) 271-9700 <br />CONTRACTOR ADDRESS 4729 W. JACQUELYN AVENUE CITY/STATE/ZIP FRESNO/ CA / 93722 <br />SUBCONTRACTOR NA PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE XC257 C-61 DE09 Other ❑ ❑ NUMBER 970772 EXPIRATION DATE 3/31/2024 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) J Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ 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 X Soil Boring(s) 5 # of borings X Geotechnical 5 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 5-50 ft Excavation 4°-7" 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 <br />Grout Seal Depth 5-50 ft Xl Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped X Free Fall [Other Tremmie ❑ Retardant / Accelerator (name) MY <br />)EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />VIRON <br />PUMP ❑Submersible❑ Turbine ❑Other HP Pump Set ft Standing Water L,MENTAL � 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 />NIINI\It N1 21 1101 R WN _0( F NO'I WE RE01 IRED I OR INSPE.( I IONS - PLEASE C 11.1. (209) 953-7697 <br />PARTMENT USE ONLY <br />Application Acc'" By Date June t, 2022 <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 5/99 Employee ID# A. Salinas <br />C SPECIAL Well Permit <br />C WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount a e Permit/ Invoice # Well ID# <br />Codes Info C h Remitted Service Re uest # <br />4372 150 $1,064 1• <br />EHD043-06 04/07! 22 ` 1 q q (r /J�TY4 q /2� Well / PumPermit Per`�MI 3 � l ) �j!/ <br />T <br />m <br />D <br />0 <br />v <br />m <br />m <br />Cn <br />to <br />