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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 9945 Benson Ferry Road CITY/ZIP Galt 95632 m <br /> D <br /> CROSS STREET Thomton Road APN 001-110-040-000 PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME Robert E. Mori 11 PHONE (209)482-5243 <br /> OWNER ADDRESS 9945 Benson Ferry Road CITY/STATE/ZIP Galt 95632 <br /> CONTRACTOR KJ Drilling PHONE (916)717-8178 <br /> CONTRACTOR ADDRESS 9700 Clay Station Rd CITY/STATE/ZIP Wilton. CA 95693 <br /> SUBCONTRACTOR N/A PHONE N/A <br /> SUBCONTRACTOR ADDRESS N/A CITY/STATE/ZIP N/A <br /> LICENSE X C-57 C C-61 ❑ D-09 ❑ Other NUMBER 1005241 EXPIRATION DATE 07/31/2023 <br /> DOMESTIC WELL SAMPLING:o General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE & Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ^ <br /> ❑ Public Water System P' <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well I9 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Borings) #of borings ❑ Geotechnical #of aft <br /> cD <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair S , <br /> tR New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingqN�OA 11, 7 �O <br /> WELL CONSTRUCTION Eq�T RpN CO <br /> Drilling Method 61 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other NOFp EZV q <br /> Proposed Well Depth-,9Q [Ze ft Excavation in diameter ❑ Open Bottom Is Gravel Pack/Gravel Size 3/8 in diam r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel R Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth rib f ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> M Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 9 Pumped D Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 19 Driller ❑ Pump Contractor ❑ Other <br /> R Concrete Pedestal❑Dimensions:Width.—ft Length A ft Thick Sit <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP R Submersible❑Turbine ❑ Other HP 3 Pump Set TBD 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 G �� //fJ�� <br /> Application Accepted By L Lr Date 121D. �a Area / Employee ID# /V/ <br /> Grout Inspection By Date Wu C SPECIAL Well Permit <br /> Pump Inspection By Date Z-7�Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ?'0 ft <br /> COMMENTS <br /> GebE ✓ t <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By, fcash Remitted -Jervice,Request# <br /> 390 sl C- 41&-6 2 1131a P 0 I !_� <br /> 70 ITO t yao 12 IS J0 q L410 <br /> y 3cj 1 #ISS I !.) <br /> 434a. ¢76 1 0 WOD N <br /> N <br /> EHDO43-06 04/07/2022 Page I of 2 Well/Pump Permit O <br /> C6x /53 86/1 -7 <br />