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T <br />I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (LUU) yb3-/by/ FOR INSPECTIONS tAt'IKtJ 'I TEAR FROM UATE ISSUED <br />JOB ADDRESS 563 Carolyn Weston Blvd. cITY/ZIP Stockton, 95206 <br />CROSS STREET MANTH EY RD APN 164-220-00 PARCEL SIZE I - S 6 LAND USE APPLICATION # <br />OWNER NAME sevenly Grovo b PHONE <br />OWNER ADDRESS 0LIO I"►'�aeAr`th"r 91V� ��e ��� CITY/STATE/ZIPNewParJ <br />ICONTRACTOR <br />ICONTRACTOR ADDRESS <br />SUBCONTRACTOR Technicon Engineering Services, Inc. <br />CITY/STATE/ZIP <br />PHONE <br />PHONE 559-276-9311 <br />SUBCONTRACTOR ADDRESS 4539 N. BraWley Ave. Suite 108 CITY/STATE/ZIP Fresno, CA 9372.t2� <br />LICENSE R C-57 n C-61 [ID -09 ❑ Other NUMBER 767888 EXPIRATION DATE Nr„31 �.3 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural [] Industrial ❑ Water Quality Monitoring K 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 />PA <br />❑ Monitoring Well(s) # of wells R Soil Boring(s) # of borings Geotechnical <br />cc <br />5 ° n` C N <br />F Out -Of -Service Well f_l Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />CEF/VFX <br />❑ New Pump Pump Replacement [I Pump Repair [] Raise Well Casing <br />WELL CONSTRUCTION <br />7 <br />20 <br />Drilling Method [ I Mud Rota I I Air Rotary J(1 Auger I I Cable Tool uPush Point [ i Other SAN �� <br />/ <br />0-5' ' ter <br />Proposed Well Depth ft Excavation 411 in diameter C7 Open Bottom F1 Gravel Pack/GraveNVQ1 <br />T <br />LlConductor Casing in diameter / Conductor Casing Depth ft <br />T� N DE gRT-Tq� <br />MENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel <br />/ <br />❑Other <br />Grout Seal Depth_Q —� ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Ll Pumped ❑ Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />L:.I Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in LI Christy Box [:] Stove Pipe <br />PUMP ❑ Submersible❑ Turbine 1.1 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) 953-7697 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS TrCmJC <br />DEPARTMENT USE ONLY <br />Date S 7 ;t <br />Date <br />Date <br />Date <br />Area Employee ID# • ' <br />❑ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth _ <br />j 0r arovr1G/wa+For <br />ft <br />mm <br />D <br />0 <br />0 <br />m <br />to <br />PE SC Received <br />Codes Info <br />heck#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />37a sa <br />X106 "' '" <br />EHD043-06 04/07/2022 Page I of 2 Well / Pump Permit <br />