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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 17423 S. Enterprise Rd. CITY/ZIPEscalon 95320 m <br /> CROSS STREET N. of Hwy 120 APN 229-26-004 PARCEL SIZE 1•00 LAND USE APPLICATION# v <br /> A <br /> OWNER NAME Andrew Anderson PHONE 209-404-9550 N <br /> OWNER ADDRESS 17423 S. Enterprise 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/STATE/ZIP Modesto, CA 95356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Xl C-57 ❑ C-61 11 D-09 n Other NUMBER 290813 EXPIRATION DATE 5-31-24 <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE N Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring H Soil Sampling/Characterizatipp <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number D <br /> TYPE OF WORK ❑ New Well X Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> i 7 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical Sq Pf borings"Q? <br /> I I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair EN�qQv/N <br /> E New Pump ❑ Pump Replacement Li Repair ❑ Raise Well Casing NEALT RCNMECCU Ty <br /> WELL CONSTRUCTION RTME <br /> Drilling Method X Mud Rotary ❑ Air Rotary Li Auger [I Cable Tool El Push Point ❑ Other <br /> T <br /> Proposed Well Depth 260 ft Excavation 12 in diameter ❑ Open Bottom X Gravel Pack/Gravel Size no. 6 in diameter <br /> ri Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched SDR21 11 Steel CXPlastic 11 Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X Bentonite(20%solids) !I Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller iX Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal f-Dimensions:Width ft Length ft Thick <br /> in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine �i 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 /> NIININII NI ;I 110( R ADVAN('t:No II( F RI1QlIRVD I.OR INSPIJ I IONS-PLEASE CAI,I-t2091 453-7697 <br /> DEPARTMENT USE ONLY t� / <br /> Application Accepted By Date 7 a S Area / Employee ID# �1 C7 <br /> Grout Inspection By Date Z S ASV.2 0'L'� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS SEt?PfG►�@ lea rv►�t��PQ(�E �Y DV IM 12 (oOQcZ <br /> PE SC Received Chec Amount Date Permit( Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> 370 o yao Z 27 y S <br /> 143g) �EE <br /> 1-S — ON 39Q <br /> ElID043-06 10/25/2021 Page I oft Well/Pump Permit <br />