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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 7761 W. Undine Road CITy0p Stockton, CA 95206 m <br /> D <br /> CROSS STREET Howard Road APN 189.200-066 PARCEL SIZE LAND USE APPLICATION# p <br /> — a <br /> OWNER NAME Bixler Ranch PHONE (209) 462-0208 M <br /> OWNERADDRESS 7761 W. Undine Road CrryISTATEMP Stockton, CA 95206 <br /> CONTRACTOR BSK Associates PHONE (209) 769-4734 <br /> CONTRACTOR ADDRESS 550 W Locust Avenue c1rY1sTATE/LP Fresno, CA, 93650 <br /> SUBCONTRACTOR BSK Associates PHONE (209) 769-4734 <br /> SUBCONTRACTOR ADDRESS 550 W Locust Avenue clTylsrATE/ZIP Fresno, CA, 93650 <br /> LICENSE X C-57 n C-61 ❑ D-09 ❑Other NUMBER 490942 EXPIRATION DATE 12/31/2022 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDER USE ❑ Domestic/Private ❑ Irrigation/Agricultural Cl Industrial ❑ Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑ Public Water System <br /> Ir ci fererd from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well ❑ Replacement Well ❑Well Alteration/Modification Other <br /> I 1 Monitoring Well(s) #of wells Soil Boring(s) #of bonNs X Geotechnical 4x 10' tt o1 bo Ings <br /> F1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal L� Cross-Connection Repair <br /> u New Pump L I Pump Replacement ❑ Pump Repair u Raise Well Casing <br /> WELL,CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑Air Rotary -;Auger Cable Tool t I Push Point X Other hand auger borings <br /> Proposed Well Depth 10 ft Excavation 4" in diameter ❑ Open Bottom ❑Gravel Pack/Gravel Size in diarpRter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft A <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched a Steel [I Plastic ❑ Stainless Steel ❑Other `: V <br /> Grout Seal Depth ft X Neat Cement(94 Ib bag15 10 gal water) ❑ Sand Cement sack mixl7 gal w t / c <br /> n Bentonite(20%solids) ❑ Other `O <br /> Grout Placement Method ❑ Pumped X Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Other J <br /> n Concrete Pedestal[]Dimensions:Width ft Length ft Thick <br /> lin G Christy Box ❑ Stove Pipe T O- <br /> Tq� TY <br /> PUMP ❑ Submersible El Turbine O Other HP Pump Set ft Standing Water Level ft MF^/T <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water wel] 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 /> MININIURf 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC-110\S-PLEASE CALL(209)913-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By `�����/'� Date �-2.2 Area 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 /> PE SC Received Check#/ Amount Data Pemily Invoice# Well ID# <br /> Codes Info B Ca h Remitted Seryice Request# <br /> ElID043-06 1025/2021 Page 1 ort Well/Puny Penna <br /> Lz7� --I-$/�� 'G9s--A,/ <br />