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a . <br /> 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 /> rn <br /> JOB ADDRESS 26684 F Vine Ave cITYmP Escalon 95320 m <br /> E. of Reile Ave. 227-36-008 1.01 D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> M <br /> OWNER NAME Teresa Olson PHONE 209-765-1096 y <br /> OWNER ADDRESS 26684 E. Vine Ave. CITYISTATE/ZIP Escalon, CA 95320 <br /> CONTRACTOR Hennings Bros. Drilling Co., Inc. PHONE 209-545-1185 <br /> CONTRACTOR ADDRESS 1930 Ladd Rd. CrTYISTATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 n C-61 11 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 K 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 Y, Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11 Monitoring Well(s) #of wells ❑ Soil Boring(S) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 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 250 ft Excavation 14 in diameter ❑ Open Bottom X Gravel Pack/Gravel Size co- 6 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel 9 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) ❑ Other <br /> Grout Placement Method C)(Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller E(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 2001 radius of proposed well. <br /> NIININIUM 24 HOUR ADVANCE.NOTICE,REQUIRED FOR INSPECTIONS-PLEASF.CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 07 Area �� Employee ID# <br /> Grout Inspection By ,5e-61 — Date 20 7`7 ❑ SPECIAL Well <br /> Pump Inspection By Date n WAIVER ReC <br /> Soil Boring Inspection By Date Constructed Well Deptlr ft <br /> COMMENTS 'E,-r f } ✓J C) o / J <br /> 31- 7 q —/i 9 ez,y3 <br /> PE SC Received ec Amount Da Permit Irll M�jy� D# <br /> Codes Info B ash Remitted Service RQ uest# av <br /> 378 1�P <br /> �311 S <br /> EliDO43-0610125/202 t Pap t ore win i Pump Po i1 <br />