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1 <br />` 1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 . (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL lUy 9b3-/b9f FOR INSPECTIONS tAI'IKtJ 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS aOSS Vierra Road Cm/LP Lathrop <br />p , / See plot map p <br />CROSS STREET /Lf G 5� APNI J S' LI PARCEL SIZE O� �j u LAND USE APPLICATION # <br />(� 1 <br />OWNER NAME P. <br />the QS I wt pl D (�M pGy ry COY P PHONE �y <br />OWNER ADDRESS 1 V r0 U t� CITY/STATE/ZIP 60 ase � D O 7 <br />CONTRACTOR Far Western Anthropological PHONE 530-756-3941 <br />CONTRACTOR ADDRESS 2727 Del Rio Place <br />SUBCONTRACTOR Confluence Technical Services, Inc. <br />SUBCONTRACTOR ADDRESS 6821 8th Street <br />LICENSE CR C-57 ❑ C-61 ❑ D-09 C Other. <br />CITY/STATE/ZIP Davis, CA 95618 <br />PHONE (916)760-7641 <br />CITY/STATE/ZIP Rio Linda, CA 95673 <br />NUMBER 1035255 EXPIRATION DATE 01/31/2024 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural C Industrial D Water Quality Monitoring >X Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑ Well Alteration/Modificatio LiOther <br />❑ Monitoring Well(s) # of wells XI Soil Boring(s) 30 # of borings ❑ Geotechnical <br />Cl Out -Of -Service Well ❑ Out -Of -Service Well Renewal i I Cross -Connection Repair <br />❑ New Pump ❑ Pum R� lacement ❑ Pump Repair 00 i ❑ Raise Well C si <br />,, CIV', <br />l VFb <br />WELL CONSTRUCTION jKev lSe p -A 'gll—l U b 202 <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary :1 Auger Li Cable Tool N Push Point Li Other SAN J � <br />Proposed Well Depth 30 ft Excavation 4 inches in diameter ❑ Open Bottom ❑ Gravel Pack/Grav*i V,/Rn",•• Qo <br />it ueter� <br />El Conductor Casing in diameter / Conductor Casing Depth ft 'rt DEPA,F TTA"Lv f Y <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other ART MENT <br />Grout Seal Depth 30 ft IK Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped [(Free Fall CX Other Tremie Pipe ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller C Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SUbmerSlble❑ 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 />NII\INIUNI 24 FTOUR ADVANCE NOTICE REQUIRED FoR INSPECTION'S - PLEASE (:'LLL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted Byff <br />Date '% r a?' _ Area 3 LC; )'ra Employee ID# <br />Grout Inspection ByJ Date :1 SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />tt <br />to <br />A <br />D <br />0 <br />0 <br />rpn <br />y <br />V) <br />PE <br />Codes <br />SC Received Check#/ Amount D to Permit/ Invoice # Well ID# <br />Info Bv Cash Remitted ervi a Re uest # <br />y3'7 2 <br />150 qqqJy <br />UND043-0604/0712022 Page l of 2 �dd � �� ATO �t��(t'1�5 f'Lt , 11i Pwry, Pr'M <br />' N432 -Z -`l S� $/i 6/ 2� Z l� � E;4�wa iCc I I `t 8 Z2 44 l <br />