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t <br />I ' <br />I - WELL/PUMP PERMIT <br />USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (:ALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS 8858 E. fairchild rd CITY/ZIP Stockton, ca 95215 <br />CROSS STREET Alpine <br />OWNER NAME David Gai <br />OWNER ADDRESS 8858 E. Fairchild <br />APN 08908003 PARCEL SIZE lacre LAND USE APPLICATION # <br />PHONE 480-296-5872 <br />CITY/STATE/ZIP Stockton, Ca 95215 <br />CONTRACTOR GOLDEN STATE IRRIGATION & PUMP SERVICE <br />CONTRACTOR ADDRESS 4500 E FREMONT <br />SUBCONTRACTOR N/A <br />BCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 )( C-61 ❑ D-09 ❑ Other, <br />PHONE 209-943-7774 <br />CITY/STATE/ZIP Stockton 95215 <br />CITY/STATE/ZIP <br />NUMBER 979833 <br />PHONE <br />EXPIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING: U General MineraiiConforfrt Bacteria (4391) u Dibromochioropropane (4392) Li Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ 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 ❑ Cross -Connection Repair <br />New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft N <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other _ <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bagl5-10 gal water) ❑ Sand Cement sac W?5 11 <br />❑ Bentonite (20% solids) ❑ Other <br />[Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) AP n _ <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal [I Dimensions: Width ft Length ft Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUMP 1i Submersible[] Turbine ❑ Other HP 3 Pump Set 185 ft Standing Water Level 120 ''KRA <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 anv water wells or surface water within 200' radius of proposed Well. <br />)IININ'II 41 24 ttOI'iZ :U)l ckN('f NO'l 1(`t,: litCt)l I1i1SD hOK I1SPll CIIONS - I'11:.i5t: ('A1.1 )209) 953-7('97 <br />DEPARTMENT USE ONLY <br />Application Accepted By � Date 3 c� Area I Employee ID# F(L'^, Ilk <br />Grout Inspection By A Date ❑ SPECIAL Well Permit <br />Pump Inspection By o Date b 2 ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS Nei) V,, dm) t W POO L1 a 5-6 9 <br />N <br />M <br />M <br />D <br />0 <br />M <br />m <br />m <br />EnN <br />PE <br />Codes <br />Sc Received (CheckV Amount Da Permit/ Invoice # Well ID# <br />Info B Remitted Service Re uest # <br />L: p <br />051 3 <br />EH13043-06 10/25/2021 Page I of 2 WeII / Pump Permit <br />