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1 WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 700 Yosemite Ave. cITYrz Escalon, CA 95320IP m <br /> d 225-02-021 D <br /> CROSS STREET West of Escalon-Bellota R�4PN PARCEL SIZE 36.26 LAND USE APPLICATION# z <br /> OWNER NAME Groh ne-Negley-Pappa PHONE 559-760-9109 Brian y <br /> OWNER ADDRESS 903 Pine St. CITYISTATE/ZIP Manteca, CA 95336 <br /> CONTRACTOR Hennings Bros. Drilling Co.,lnc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 rl Other NUMBER 290813 EXPIRATION DATE 5-31-24 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X 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 EX Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> =i 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 X Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ails ft Excavation 12„ in diameter ❑ Open Bottom XGravel Pack/Gravel Size No. 6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel (Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 126Q' 15&ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller X Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> �in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the followin .It 111fWS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing vie 'strltetores, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. Po"r Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> '.IIV'[iltl�Y 24 IIODR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PIA'ASE CALL(209)9z;3-7697 <br /> <1�21EP RTMENT, USE N L Y r r /, <br /> Application Accepted By Date Areal Employee ID# .c/dU Grout Inspection By Date LaiT? 13 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date ! Constructed Well Depth ft <br /> COMMENTS ln2 T:1r 4 t['Cd' r j��L� ue' tL> �f'�� hi;de- t/1 tcr!�T ►Di'/. �Ic.1 VP,Y� l.4 3C-5 <br /> d(fl2t"} ,BPS L 0.rO ,ZC3 r'OC1{r.f/r,f�v1: -VV. <br /> PE SC Received Check#/ Amount Permit/Codes 1 fo Cas emitted Date Service Request Invoice# Well ID# <br /> 22 130 )1 <br /> ElID043-06 10/25/2021 Page I of 2 Wcll/Pump Permit <br />