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EMAILED <br /> 1 _12'"7 sa 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 /> 7 -M <br /> JO©ADDRESS — CITY/ZIP K 5 2 LZ m <br /> CROSS STREET I1 / 1y t Y_ APN 0, V/+Ily-VO LPARCEL SIZE LAND USE APPLICATION <br /> OWNER NAME / h nt. C� i OPHONE 20IC- 9V#1-Zl� 3 OA <br /> N <br /> OWNER ADDRESS 40`/ 1 CITY/STATE/ZIP (fp(A_� , C✓yto <br /> 11 52 1 Z <br /> CONTRACTOR MASELLIS DRILLING, INC. PHONE 209-522-1928 <br /> (CONTRACTOR ADDRESS 119 ALBERS RD. CITY/STATE/ZIP MODESTO, CA 95357 <br /> I <br /> 1 SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 L C-61 D-09 Other NUMBER 668622 EXPIRATION DATE 04/30/202 <br /> DOMESTIC WELL SAMPUNG: )(General Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural Industrial - Water Quality Monitoring C.i Soil Sampling/Characterizatio <br /> Public Water System k NT <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )(New Well Replacement Well L: Well Alteration/Modification '_1 Other 0 <br /> Monitoring Well(s) #of wells 1, Soil Boring(s) of borings Geotechnical °rhonngs43 <br /> Out-Of-Service Well Out-Of-Service Well Renewal -1. F <br /> Cross-Connection Repair N` 4. <br /> /Oq <br /> NEN�IR Qv/N� <br /> _ New Pump Pump Replacement !' Pump Repair ' Raise Well Casing 41 0 0 <br /> WELL CONSTRUCTION pgRr <br /> ry <br /> Drilling Method )(Mud Rota Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_��_ft Excavation �Z„ in diameter Open Bottom XGravel Pack/Gravel Size=in diameter <br /> Conductor Casing in diameter / Conductor C��sing Depth ft <br /> Well Casing Diameter lL � <br /> in Thickness/Gauge/ASTM Sched—�– Steel 'Plastic '1 Stainless Steel Other <br /> Grout Seal Depth 10 0� ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> �(Bentonite(20%solids) ❑Other <br /> Grout Placemen{`Method XPumped _� Free Fall Other i 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 well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> %ii\i\ii Ni 24 HOI!t \U\ I I it I R1 Q11 IRED FOR INSPF( i it)`',-PI.FASF CAL(-(2091953-7h4- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date /0/,&/�3 Area 7` / 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 <br /> rp G GtCCrrrP/�� W��� <br /> PE SC Received Check#/ Amount Dare PermlU Invoice# Well Ill <br /> Codes Info Cash emitted Service Request# <br /> VS7F Zko o IZ(P(42-6 <br /> 9 <br /> EHDO43-06 04/0752022 Par 1 of 2 Wc111 Pump Permi <br />