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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 /> to <br /> JOB ADDRESS <br /> it 850 S. Stale C:Out:--, :i : CITY/ZIP Ti m <br /> D <br /> v <br /> CROSS STREET East p1r 1-5 APN �' -I'�'- PARCEL SIZE f-'. ' LAND USE APPLICATION# m <br /> OWNER NAME Deter Reece PHONE 209-602-8475 � <br /> OWNER ADDRESS :;085-iD H"'J K" CITY/STATE/ZIP Tracy, CA 95304 <br /> CONTRACTOR 1-.ent ings arcs. Dritiling Ca., it,", PHONE 209-545-1 I lia <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP IMOdesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Gf.C-57 n C-61/' ❑ D-09 ❑ Other NUMBER 290813 3 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ✓General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE 0,Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial f7 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 0 New Well jL Replacement Well ❑ Well Alteration/Modification 0 Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C3(Mud Rotary D Air Rotary fJ Auger ❑ Cable Tool ❑ Push Point D Other <br /> Proposed Well Depth 20() ft Excavation in diameter ❑ Open Bottom h Gravel Pack/Gravel Size i"UO. 6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched S >RA ❑ Steel X Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth '1 i00 ft ❑ Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> g.Bentonite(20%solids) 0 Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller U.Pump Contractor 0 Other <br /> 0 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine D 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 /> NIT�IfNJUM 2.4 HOUR AIY"r!.AICVfi :'40-TIEE RtQf,;TF'ED'IrG*>_'tf.�rPECTTr7NN-PI.E St C-ALT—fZ"Y!rc; <br /> DEPARTMENT USA ONLY c <br /> Application Accepted By Date <br /> /v(Z� Zr Area ✓ /�� Employee ID# <br /> Grout Inspection By Date I ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Well . lecfCh,,' ivell / wt <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# ,G Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 37 V r.4­ 1024-95 KI P a501a5a <br /> 9�r 990 Q <br /> IN 0. O <br /> T <br /> EHD043-06 04/07/2022 Page 1 uf2 well!Pump Permit <br /> Uploaded into Accela <br />