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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 20087 Ellis Rd. CITY/ZIP Escalon 95320 rn <br /> m <br /> D <br /> CROSS STREET South of Clough Rd. APN 247-14-021 PARCEL SIZE 4.92 LAND USE APPLICATION# p <br /> A <br /> OWNER NAME Jack Swisegood PHONE 209-602-5011 N <br /> OWNER ADDRESS 20075 Ellis Rd. CITY/STATE/ZIP Escalon, CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CITY/STATEIZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE X C-57 " C-61 F-1 D-09 i-I Other NUMBER 290813 EXPIRATION DATE May 31, 2024 <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391))(Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private I i Irrigation/Agricultural Fl Industrial I Water Quality Monitoring F1 Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well XReplacement Well Well Alteration/Modification n Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings I Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method IX Mud Rotary 11 Air Rotary i 1 Auger C Cable Tool i i Push Point F1 Other <br /> Proposed Well Depth 300 ft Excavation 14 in diameter it Open Bottom X Gravel Pack/Gravel Size No. 6 in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR21 H Steel iXPlastic I I Stainless Steel n Other <br /> Grout Seal Depth 200 ft I Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br /> X Bentonite(20%solids) Other <br /> Grout Placement Method (X Pumped i 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 a Stove Pipe <br /> PUMP : Submersible[' Turbine 11. 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 U ONLY <br /> Application Accepted B _ Date Z 3 Area 9� Employee ID# MIS <br /> Grout Inspection By Date L SPECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 0y, Cash Remitted Service Request# <br /> 95 <br /> 7 / ? 3,z3 <br /> 9l i ss' <br /> 392 7 Ca <br /> EIID043-06 10/252021 1'agc I of 2 Well/PUMP Pd <br />