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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 5606 W. Linne Rd. CITY/ZIP Tracy 95304 m <br /> CROSS STREET E. of Banta Rd. APN 253-33-025 PARCEL SIZE 3'00 LAND USE APPLICATION# O <br /> A <br /> OWNER NAME Genevieve Conine PHONE 209-835-5227 y <br /> OWNER ADDRESS 5606 W. Linne Rd. CITY/STATE/ZIP Tracy, CA 95304 <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 1-I Other NUMBER 290813 EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/CharacterizatiorPA'` <br /> ❑ Public Water System �'1]' r <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 9 New Well ❑ Replacement Well ❑ Well Alteration/Modification 7 Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnlcal #o Nb4? 2Q <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal (-1 Cross-Connection Repair ANJp <br /> 7 New Pump ❑ PumpReplacement ❑ PumpRepair ❑ Raise Well CasingE�/qQ,. C <br /> WELL CONSTRUCTION QE 117 <br /> Drilling Method X Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other E <br /> Proposed Well Depth 220 ft Excavation 12 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size no.6 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR21 [ISteel X Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box 7 Stove Pipe <br /> PUMP ❑ Submersible[] Turbine [I 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)95;-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `- Date g.� Area 5 Employee ID#� <br /> Grout Inspection By c Date 1 Z Z- I.] SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS OYE 0 let I/ f",t: C? C <br /> III <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> O <br /> N3cl <br /> E11D043-06 10/25/2021 Page I of 2 Wcll/Pump Permit <br />