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1 r WELUPUMP 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 33720 S. Koster Rd. CITY/ZIP Tracy 95304 <br /> CROSS STREET N. of Hwy 132 APN 255-16-014 PARCEL SIZE 2.54 LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Jim Thoming PHONE 209-601-2706 H <br /> OWNER ADDRESS 33720 S. Koster Rd. bl-�Ca O Ko:53er CITY/STATE/LP Tracy, CA 95304 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/zIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPUNG:X General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X 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 X 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 /> ❑ New Pump ❑ Pump Replacement [I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rota I] Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 26Z it Excavation 14" in diameter ❑ Open Bottom 4�Gravel Pack/Gravel Size no.6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter 8,, in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel O(Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100' ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Al Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller A Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set 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 /> VI111V11111 24 110UR.ADVANCE NOTICE REQUIRED FOR INSPECT IONS-PLEASE CALI.(2119)953-7697 <br /> DEPARTMENT USE ONLY P <br /> Application Accepted By Z_ Date Ii v76 a 2 Area J Employee ID# <br /> Grout Inspection By Date 2J 2 ❑ SPECIAL Well Per <br /> y <br /> Pump Inspection By Date C WAIVER R@CeIV k- !��Jvr <br /> Soil Boring Inspection By Date Const cted Well Depth C It <br /> COMMENTS &.xii HYI4 we l 16 l er"et;>7• fPcao I f� gl 0 _ <br /> tRA I.M Ven IeK%' Y " <br /> PE SC Received c Amount Date Permit/ Invoi O /N <br /> Codes Info B as Remitted Service Request# T NM <br /> 179 :� f L 2 ZZ (W d '9RT <br /> q3q I lsSJ dl <br /> F-_ <br /> EHD043-06 10/25/2021 t — Page I of 2 Well/Pump Permit <br /> X wed� f <br />