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t <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS 1125 North Union Road <br />CALL 11Uy1 y5J-t J/ FOR INSPECTIONS <br />CROSS STREET East Louise Rd APN 202-260-360-000 <br />OWNER NAME 1 st Christian Church <br />OWNER ADDRESS 1125 North Union Road <br />CONTRACTOR Cal-Nev Geo Exploration <br />CITY/ZIP <br />t:AVIKtb I YEAR FROM UATE ISSUED <br />Manteca CA. 95336 <br />PARCEL SIZE3.97 aCresLAND USE APPLICATION # N/A <br />PHONE 209-624-3671 <br />CITY/STATE/ZIP Manteca, CA, 95336 <br />PHONE 916-778-0089 <br />CONTRACTOR ADDRESS 1079 Sunrise Avenue, Suite B-339 CITY/STATE/ZIP Roseville, CA, 95661 <br />SUBCONTRACTOR Allerion Consulting Group, Inc. PHONE 916-742-5096 <br />SUBCONTRACTOR ADDRESS 1050 Melody Lane, Suite 160 CITY/STATE/ZIP Roseville, CA, 95676 <br />LICENSE 8 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1039188 EXPIRATION DATE 05/31/2024 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) L 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 0 Soil Boring(s) # of borings N Geotechnical 1 # 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 />Drilling Method ❑ Mud Rotary ❑ Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 50 feet ft Excavation 4" hole in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 50 feet It ■ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sa3ffl <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ■ Other Tremie Pipe ❑ Retardant / Accelerator (name) ►AAV n <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />'"�N,,,o nuMFNTAL <br />�in ❑ Christy Box ❑ Stove Pipe HEALTH DEPARTMENT <br />PUMP ❑ SubmersibleD 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />// DEPARTMENT USE ONLY ,,�I L �'/ <br />Application Accepted By 'L " Date S 5 1 Area I ° 4 0 6C' - Employee I D# A ` � <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Z Constructed Well Depth ft <br />COMMENTS <br />T <br />D <br />0 <br />0 <br />m <br />m <br />N <br />m <br />PE SC Received C eck#/ <br />Codes Info h <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />7a <br />s6 ZZ101) <br />EHD043-06 / 7/202 ' �/ ��� . / P:iee I g42.n Well / Pump Pennit <br />3 ` '(} V /j <br />