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(�, C/11� <br /> 1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 12500 E. Fairchild Rd. cITY/ZIP Stockton. CA 95215 m <br /> D <br /> CROSS STREET E. of Jack Tone Rd. APN 089-18-010 PARCEL SIZE 10 ac• LAND USE APPLICATION# <br /> m <br /> OWNER NAME Eugene Muzio PHONE 209-482-7670 y <br /> OWNER ADDRESS 12500 E. Fairchild Rd. CITY/STATE/ZIP Stockton, CA 95215 <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/ZIP <br /> LICENSE %i'1 C-57 it C-61 1 D-09 1 Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPLINc:X General Mineral/Coliform Bacteria (4391)X Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE �.Domestic/Private ❑ Irrigation/Agricuitural ❑ 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 i Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Weil(s) #of wells ❑ Soil Boring(s) #of borings E Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ^I Mud Rotary ❑ Air Rotary P. Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 260 ft Excavation in diameter ❑ Open Bottom ':I Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft Ei, <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel �i Plastic ❑ Stainless Steel h° �' 'ENT <br /> Grout Seal Depth 200 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement 1,F CF4kf Mal water <br /> U,Bentonite(20%solids) ❑ Other <br /> Grout Placement Method IX Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1_i. Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick S <br /> in ❑ Christy Box ❑ Stove Pipe ,T <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 /> :viINiNiUNJ 24 HOUR AI)VANCEINOTWL REQLi•iRE0 i3Olt LNSPECT iONS-PLLASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L Date Area / Employee ID#lqq 146 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well epth ft <br /> COMMENTS f)O i In E- A/ }' , $ e-,l ,Y !/e.. cl. <br /> — <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 4 7? Rv 30 Q W-20-5 wMti)44-yrs <br /> I <br /> 3 � <br /> EIID043-06 10/25/2021 Pagc I orZ Wcll/Pump Permit <br />