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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZUU) y53-fby/ FOR INSPECTIONS tArIKtJ -1 TLAN f KUM UAIt IS5U1t1U1 <br />JOB ADDRESS 1970 MCHENRY AVE CITY/ZIP Escalon, CA <br />CROSS STREET Cod� ��u//n��trywood Lane Dr. APN'/227-32-02�3J � PARCEL SIZE 1' -1 LAND USE APPLICATION # <br />OWNER NAME 1AAe_s4V'/-0-od 1. ,,,ftV Veyt4rre fes` PHONE <br />I / y ry� <br />OWNER ADDRESS 1/;?;?o,ALM 4r- S�)'fe 4010 <br />CONTRACTOR Technicon Engineering Services, Inc. <br />CONTRACTOR ADDRESS 4539 N. Brawley Ave. Suite 108 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 C-61 n D-09 ❑ Other <br />NUMBER <br />CITYISTATE/ZIP Che r/0 fte , N L Oo?V'7'7 <br />PHONE 559-276-9311 <br />CITYISTATE/ZIP Fresno, CA 93722 <br />PHONE <br />CITY/STATE/ZIP <br />767888 EXPIRATION DATE N/A <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private D Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring R 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/Mo ification ❑ Other <br />D Monitoring Well(s) # of wells R Soil Boring(s) u of borings R Geotechnical 5 # of borings q 1� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing CE <br />WELL CONSTRUCTION 4Y <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool D Push Point D Other SA.. <br />Proposed Well Depth 0-50' ft Excavation Orr in diameter D Open Bottom ❑ Gravel Pack/Gravel Size 1_F�yO <br />[,I Conductor Casing in diameter / Conductor Casing Depth ft �� r ROA/ C <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad D Steel ❑ Plastic ❑ Stainless Steel ❑ Other NOF MEN <br />Grout Seal Depth a -SV ft Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal wa E <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick <br />n ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ 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 />�7 DEPARTMENT %USE ONLY <br />Application Accepted By-/�L� Date Area ^SGG�ati► Employee lD# Avr.., <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspectipn By Date dS U�2-�zZ- Constructed Well Depth ft <br />COMMENTSTIrerv�le p)De to i6e U if deeper f1Gn 3D 4i �r CfWk'dV4e4f0r J':5P,h[.n�i►I1tir� <br />T <br />1 <br />m <br />D <br />O <br />O <br />m <br />m <br />N <br />N <br />�r <br />,NTy <br />Nr <br />EHDO43-06 04/072022 Page 1 of 2 Well / Pump Permit <br />//.�A0UM <br />:I IO2i 1,offNx M <br />EHDO43-06 04/072022 Page 1 of 2 Well / Pump Permit <br />