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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 /> to <br /> JOB ADDRESS 30573 E. Combs Ave. CmrZP Escalon, CA 95320 <br /> D <br /> CROSS STREET E. of Sutliff Ave. ApN 249-14-006 PARCEL SIZE 6.26 LAND USE APPLICATION# o <br /> OWNER NAME Michael Jones PHONE 209-505-2443 y <br /> OWNER ADDRESS 30573 E. Combs Ave. CITy/STATEmP Escalon, CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATEMI, Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 11 C-57 n C-61 n D-09 i-I Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 1t.Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sam pling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well N.Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ; Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> U New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 3 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ?65 ft Excavation 1`1 in diameter ❑ Open Bottom Gravel Pack/Gravel Size no.6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR2 i ❑ Steel CJ Plastic ❑ Stainless Steel ❑ r` LL <br /> Grout Seal Depth 100 ft !] Neat Cement(94 Ib bag/5-10 gal water) El Sand Cement CICRII ater <br /> i' <br /> Bentonite(20%solids) ❑ Other (CFmlsE� <br /> Grout Placement Method Pumped ❑ Free Fall ;, Other ❑ Retardant/Accelerator(name) <br /> AAAV 1) <br /> PEDESTAL Installed By ❑ Driller : ;Pump Contractor ❑ Other J <br /> -1 Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe SAN TY <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing fPARTMENTft <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 U E NL <br /> Y �fJ <br /> Application Accepted y Date 30 Area Employee ID# I I� <br /> Grout Inspection By f Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received c� t <br /> Soil Boring Inspection By Date Constructed Well Depth 1_J ft <br /> COMMENTS Ally /,! Efid, W Zo-7e—. e � /,/ /.l'IC /97 F (W- <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 3 D ' �5'3mtz wt'c�cvya5�,t <br /> EHDO43-06 10/25/2021 Page 1 of 2 well/IhU t Permit <br />