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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 />NUN-KEFUNDABLE PERMIT (:ALL (ZU9) UbJ-/by t FOR INSPECTIONS tXPIKt1 'I YEAR FROM UATE ISSUED <br />JOB ADDRESS g231 South, CA -99 6 0flfA % CITY/ZIP , Stockton, CA 95215 <br />CROSS STREET 1(G►1 APN 17726012 PARCEL SIZE 8 acres LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />PHONE <br />C • !, <br />CONTRACTOR Soils Engineering. Inc. PHONE (661) 831-5100 <br />CONTRACTOR ADDRESS 4400 Yeager Way CITY/STATE/ZIP Bakersfield, CA 93313 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS n/a CITY/STATE/ZIP n/a <br />LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 253192 EXPIRATION DATE 08/31/23 <br />DOMESTIC WELL SAMPLING: IJ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) LI Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private D Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring & Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. <br />Water System Name <br />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 IX Geotechnical 3 # 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 9 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 10' -15' ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 8" in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Ot <br />REFIT - <br />Grout Seal Depth 10' - 15' ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement I water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped rA Free Fall ❑ Other ❑ Retardant / Accelerator (name) _AI JA <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other —IV In�n'.1mrn-ITY <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ftThick ENVIRONMENTAL <br />in ❑ 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 />DEPARTMENT USE ONLY <br />Application Accepted By �� /`' Date <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By QWZYN PO <br />COMMENTS <br />Date <br />Date <br />Area__i �� (� Employee ID#A_ <br />SPECIAL Well Permit <br />WAIVER Received <br />Date' ,lS'�—RNI-Cruz-- Constructed Well Depth <br />ft <br />Received Ch ck#/ <br />Permit/ <br />L��F?11l%I RYARIAME <br />M fifVI !. . M � 1 SIMIM <br />EH 3-06 07/2022 1 4 —j/ r Exge ��f - ���1 lL 2 ,4, V$ C- s < < Well /Pump Permit <br />