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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 9851 E. Mariposa Rd., CITY21P Stockton 1#4W 0ll 215 m <br /> CROSS STREET N. of Santa Ana Way APN 181-09-003 PARCEL SIZE 3.10 LAND USE APPLICATION# z <br /> OWNER NAME Tyron Barber PHONE 510-714-2228 (n <br /> OWNER ADDRESS 16333 Lawrence Rd. Crry/STATE/ZIP Escalon, CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITyiSTATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <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 X Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> L— 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 L(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 260 ft Excavation 14" 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 8 in Thickness/Gauge/ASTM Schad SDR21 ❑ Steel X Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 200 ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method jig 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 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 /> MININII!-NI 24 110LR ADA'ANCI{NOTICE REQIL IRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 9117/;?3 Area y Employee ID# Fmtti 1f <br /> Grout Inspection By f'1 Date y ❑ SPECIAL Well Permit <br /> Pump Inspection By Date E WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Sel2e(uj"E G(rr l+ be G1eslroy tint/ pe�m/�_ <br /> PE Sc Received C,--Chec:_W Amount Permit! <br /> Codes Info B ash Remitted Date Service Request# Invoice# <br /> 4378 IBo &4q;C, v +s' 2 <br /> itr <br /> t:';"JV <br /> EH13043-0610n5n021 Page I are well i Punyr Permit <br />