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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 200287 E. Mariposa Rd. CITY/ZIP Stockton, CA 95215 m <br /> CROSS STREET / APN 20515021n <br /> PARCEL SIZE LAND USE APPLICATION# o <br /> X <br /> OWNER NAME Robert L. Alcantor PHONE z-09-401-2943 Cn <br /> OWNER ADDRESS 20287 E. Mariposa 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 C-57 C-61 D-09 Other NUMBER 2081 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural I 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 Replacement Well Well Alteration/Modification C[ Other <br /> ❑ Monitoring Well(s) #of wells '.7 Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well I Out-Of-Service Well Renewal I1 Cross-Connection Repair <br /> I New Pum Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary ❑ Air Rotary I I Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth 240' ft Excavation in diameter ❑ Open Bottom [ Gravel Pack/Gravel Size �' in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SnR?1 ❑ Steel 1,;'Plastic I I Stainless Steel I Other <br /> Grout Seal Depth 200 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> -1 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method :z Pumped ❑ Free Fall I i Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Il Driller X Pump Contractor Li Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box J Stove Pipe <br /> PUMP ❑ Submersible,l Turbine J 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE;CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area 04ti `L`l Employee ID# 1 L <br /> Grout Inspection By Date �^�Ll lZ� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS rvvVW.l <— Li ,vl I 5 l�t✓A.'- -t' 04­t <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 15-00z _ ' 4--5-)4 W P a <br /> F.HDI143-0610/252021 •/��1 �(YN�(Dn� .� n/1 ['age I oft Wcll,Pump Permit <br /> // � v'vU(JLi <br />