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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 8615 Via Carano PI CITY/ZIP Escalon 95326 fm <br /> CROSS STREET Carter APN 187-400-320-000 PARCEL SIZE 10.9 LAND USE APPLICATION# O <br /> M <br /> OWNER NAME Vince&Lisa Cipponeri PHONE (209)216-8745 y <br /> OWNER ADDRESS PO Box 630 CITY/STATE/ZIP Escalon CA 95320 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 4/11/2023 <br /> DOMESTIC WELL SAMPLING:Ci General Mineral/Coliform Bacteria(4391)u Dibromochloropropane(4392)1__ Arsenic(4393) <br /> INTENDED USE R 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 ❑ Soil Boring(s) #of borings ❑ Geotechnical 'NCf '6/V-r <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair�E1 VFp <br /> [X New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingG <br /> WELL CONSTRUCTION `^O�� <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav QUI L I meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft HEALTH pE–'`�'rgtNTq� 'y <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other RTM,ENr <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> R Concrete Pedestal DDimensions:Width 6 ft Length 24 ft Thick 9 inrh <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP g Submersible❑ Turbine ❑ Other HIP 7.ri Pump Set 200 ft Standing Water Level 19(1 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 - — Z_Z_ Date Area C� Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ate V' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS eW e I 1 0 l,1 C� <br /> PE SC Received Check#/ Amount Dat Permit) Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> ago CS-I '51 <br /> EHDO43-06 04/07/2022 Page I of 2 Well/Pump Pennit <br /> dW� /4E36�63� <br />