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1 WELL/PUMP PERMIT <br /> 2255 <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 28455 Corral Hollow Rd. CITY/ZIP Tracy/95377 m <br /> CROSS STREET W. Llnne Rd. APN 240-14-021 PARCEL SIZE 1 .95 LAND USE APPLICATION# O <br /> A <br /> OWNER NAME RetechNerizon - Contact Marla Sullivan -DgCX VeCo1 PHONE 916-833-3066 y <br /> OWNER ADDRESS 11375 Sunrise Park Dr. Ste. 600 CITY/STATE/ZIP Rancho Cordova/CA/95742 <br /> CONTRACTOR .Delta Pump Inc. PHONE 209-466-9625 <br /> CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 X C-61 0 D-09 ❑ Other NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial C 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 JV D <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of�,/ort- <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Ll Cross-Connection Repair ''IfII 12 20 <br /> ❑ New Pump X Pump Replacement Cl Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION ENVIR5�/N Cp <br /> Drilling Method '0 Mud Rotary 11 Air Rotary Ll Auger ❑ Cable Tool 11 Push Point 11 Other NEALT NN/EN TY <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size ini VT <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 11Steel [IPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) n Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box Ei Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set244 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 Q <br /> Application Accepted By LL Date & 2Za2 Area Employee ID# A <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date_ ❑ WAIVER Received <br /> Soil Boring Inspection By L Date Constructed Well Depth ft <br /> COMMENTS iJoGvYi��✓L C'apft�IrlGIfPI pF „4ell� <br /> PE SC Received eck#C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> y3Os07-7 v Z _ <br /> EHDO43-06 10/25/2021 Page 1 of 2 Well/Pump Permit <br />