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Y WELL/PUMP PERMIT 2245 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 465-3420 <br />NUN-KEFUNDABLE PERMIT GALL tZU9) 953-1b91 FOR INSPECTIONS EXPIRE -5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS h 100; Mobley Rd. <br />CITY/ZIP Stockton/95215 <br />CROSS STREET Gawne Rd APN 185-120-12 PARCEL SIZE 110.98 LAND USE APPLICATION # <br />OWNER NAME Rob and Edele Norman PHONE 209-749-4661 <br />OWNER ADDRESS PO Box 628 CITY/STATE/ZIP Stockton/95366 <br />CONTRACTOR Delta Pump Inc. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIPStockton/95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 X C-61 ❑ D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private XIrrigation/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 E. Replacement Well ❑ Well Alteration/Modification ❑ Other <br />Ab A <br />s <br />❑Monitoring Well(s) # of wells El Soil Boring # of borings s Li Geotechnical <br /># ri nA <br />c <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />`C''�7/ <br />❑ New Pum ❑ Pum Replacement Pum Repair Li Well Casing <br />c <br />WELL CONSTRUCTION <br />JU4 <br />0 <br />Drilling Method ❑ Mud Rotary -_Air Rotary Auger = Cable Tool El Push Point Other SAN U <br />Proposed Well Depth ft Excavation in diameter Open Bottom 7 Gravel Pack/Gravel QU ameter <br />riIV <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />�LTIy`a�'Cz- 41EN�Ul�T <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched E Steel C Plastic - Stainless Steel <br />-Other qR L <br />Grout Seal Depth ft - Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement <br />sack mix17 gal wa r <br />Bentonite (20% solids) ❑ Other <br />COMMENTS_ <br />Grout Placement Method E Pumped _ Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal GDimensions: Width ft Lenoth ft Thick <br />n ❑ Christy Box Stove Pipe <br />PUMP ❑ Submersibles( Turbine ❑ Other HP 75 Pump Set 160 ft Standing Water Level 125 ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: CPS <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 />IININ11 \1141V)l 11 \0\ I \1tIII I RI( l I:tn1O1,1 ,I Is 11()\,, -III I \"I I I i'u>, <br />W <br />m <br />D <br />O <br />O <br />m <br />m <br />rn <br />PE Sc Received Ch Amount Permit/ <br />Codes Info 13 Cas Remitted Date Service Request # <br />DEPARTMENT USE ONLY <br />Application Accepted By—� <br />/ / <br />L-, L , Date ��r�Ol <br />Area / Employee ID# <br />F`] <br />Grout Inspection By <br />Date <br />❑ SPECIAL Well Permit <br />Pump Inspection By <br />Date ����� �r� <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS_ <br />rco i/Pllli/I t`S d Vye )%' <br />W <br />m <br />D <br />O <br />O <br />m <br />m <br />rn <br />PE Sc Received Ch Amount Permit/ <br />Codes Info 13 Cas Remitted Date Service Request # <br />Invoice # Well ID# <br />F`] <br />EH13043-06 10/25/2021 Page I of 2 Well / Pump Permit <br />