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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />JOB ADDRESS <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS <br />14400 E St Rt Hwy 26 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />Pagclor2 Well / Pump Permit ER00-13-06 1025/2021 <br />1 WELL/PUMP PERMIT <br />Contact Name or Phone Number If different train Owner: Water System Name <br />INTENDED USE 7 Domestic/Private Irrigation/Agricultural 7 Industrial 'A Water Quality Monitoring L7 Soil Sampling/Characterization <br />Li Public Water System <br />TYPE OF WORK :11 New Well Replacement Well [.3 Well Alteration/Modification :1 Other <br />[1 Monitoring Well(s) <br />fl Out-Of-Service Well <br />7 New Pump E Pump Replacement <br />12 Conductor Casing in diameter / Conductor Casing Depth <br />Diameter _in Thickness/Gauge/ASTM Sched D Steel <br />Depth ft 17; Neat Cement (94 lb bag/5-10 gal water) <br /> <br /># of wells 11 Soil Boring(s) # of borings Li Geotechnical <br />7 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> <br />-Pump Repair 0 Raise Well Casing <br />Well Casing <br />Grout Seal <br />OCIT 2 t. <br />04n, .2022 <br />W tv(-.17 cuar.neter <br />7 Other <br /> sack mix/7 gal Water <br />WELL CONSTRUCTION <br />Drilling Method 7 Mud Rotary Li Air Rotary Auger E Cable Tool 7 Push Point C Other <br />Proposed Well Depth ft Excavation in diameter E. Open Bottom Li Gravel Pack/Gra <br />ft <br />E Plastic D Stainless Steel <br />0 Sand Cement <br />7 Bentonite (20% solids) E Other <br />Grout Placement Method E Pumped E Free Fall E Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By t: Driller C Pump Contractor Li Other <br />E Concrete Pedestal LiDimensions: Width ft Length <br />in E Christy Box :1.1 Stove Pipe <br />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 />NI 24 ZIOt12 AM* LI NOTiCE RE;;;; ' :'''J'''' FOR INSPECTIONS - PLEASE CALL 1209) 9.53-7697 <br />r <br />3yc-X1 <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By . <br /> <br />Soil Boring Inspection By <br />COMMENTS <br />Area <br />IT <br />q 9 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />PARTMENT U/3 ErLY <br />Date l° Z5C <br />Date <br />Date <br />Date <br />fib <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />. i Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />V3k2- 05-0 AP- Visei— . 5727 110-5. 1Z 1400(-13%03 <br />. ... <br />) <br />0 Submersible)<Turbine E Other HP Pump Set /7o ft Standing Water Level <br />ft Thick :SSEHOCIV 3.1.1S PUMP <br />CITY/ZIP <br />OWNER NAME Schenone Farms <br />2 Other 7/31 /2 3 EXPIRATION DATE NUMBER 377923 LICENSE gx7C-57 Li C-61 U D-09 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Linden, CA 95236 <br />Jack Tone <br />CROSS STREET APN /6"5 6.20,27 PARCEL SIZE 10' 3 LAND USE APPLICATION # <br />14400 E Hwy 26 OWNER ADDRESS <br /> PHONE <br />Linden, CA 95236 <br />ciTyisTATEiziP <br />Inc CONTRACTOR <br />n/a <br />PHONE 209-887-3554 <br />Linden, CA 95236 CITY/STATE/ZIP <br />Purviance Drillers, <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />PHONE <br />CITY/STATE/ZIP