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EMAILED <br /> 1 19-7 S!i 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 /> _ �/1 7 N <br /> JOB ADDRESS 30 H I CITY/ZIP ` ` m <br /> yy� /n A\k �J� �� n <br /> CROSS STREET Al rum f h1 Q �/(�1 / I V�I APN n(� yt_j PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME C(Af I I JI i ne, l i n t _ PHONE 2011- 951-2-N5 N <br /> Rc�,-lam 110' �1-{1-�,n �`�\ 4l <br /> OWNER ADDRESS �/l ,Zo 1 I I I b1V vl► ( L n _ CITY/STATE/ZIP (St1�� 11.,7 I. CA 175212- <br /> CONTRACTOR <br /> 7521ZCONTRACTOR MASELLIS DRILLING, INC. PHONE 209-522-1928 <br /> CONTRACTOR ADDRESS 119 ALBERS RD. CITY/STATE/ZIP MODESTO, CA 95357 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 IC-61 D-09 Other NUMBER 668622 EXPIRATION DATE 04/30/2025 <br /> DOMESTIC WELL SAMPLING: XGeneral Mineral/Coliform Bacteria(4391) )(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural i Industrial Water Quality Monitoring [; Soil Sampling/Characterizatio9h�+ M <br /> Public Water System �_('%% N r <br /> If different from Owner. Water System Name Contact Name or Phone Number ^ <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification U Other U&C 11cO <br /> #of borings of borings <br /> Monitoring Well(s) #of wells Soil Borings) Geotechnical�4 <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair H /v Q(J/� <br /> New Pump Pump Replacement Pump Repair ❑ Raise Well CasingFq� RO COT <br /> 'WELL C ONSTRUCTION pQR y <br /> I Drilling Method XMud Rotary " Air Rotary I i Auger - Cable Tool ❑ Push Point i Other TM T <br /> Proposed Well Depth Z7_w ft Excavation 12„ in diameter ❑ Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor C sing Depth ft <br /> Well Casing Diameter-1L in Thickness/Gauge!ASTM Sched Steel Plastic -1 Stainless Steel Other <br /> Grout Seal Depth j 0 0� ft Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> NJ <br /> Bentonite(20%solids) Other <br /> Grout Placemen Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller 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 Nell,provide location of any water wells or surface water within 200'radius of proposed well. <br /> SII\INL.N2411ULR.aIYCA\C'EVUl7i '. ; rlIIRN.1)FOHI\�YEC17U��-PLFA>I'l •11.1.1'-tl91Yi3-7b4; <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date /?3 Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS G ctCC'vrrP�s� W�l� <br /> PE SC Received Check!/ Amount Date Permit/ Invoice 8 Well IDX <br /> Codes Info h emitted Service Request# <br /> 'I_?7,F Llv i2(olo 23 w('� 15t�CG <br /> 9 S <br /> y & - <br /> EHD0434)6 04107/2022 Pec 1 of 2 Wcll I Purttp Permit <br />