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I <br />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 3263 E. Cherokee Road crrY/zIP Stockton / 95205 <br />(A, s) <br />CROSS STREET Newton Road APN 132-070-100-000 PARCEL SIZE 139.$000 LAND USE APPLICATION# <br />OWNER NAME Randall P Etal Raj kovich - Contact: Jerry Grunzinger, KP Development 314.960.0843 <br />314.960.0843 <br />OWNER ADDRESS 8025 Forsyth Boulevard CITY/SfATE/zIP at. LOUis, MO 63105 <br />CONTRACTOR West Coast Exploration - Andrew Hernandez, Owner/Operator PHONE 209.985.7541 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE/ZIP Escalon, CA 95320 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01/31/2020 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Nam or Phone Numoer <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWeil s # of wells Soil Borin s "borings borings # of borings <br />O gO X Geotechnical �_ <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />)rilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />2roposed Well Depth 5 to 20 It Excavation 41/2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depthfull depth It X Neat Cement (941b bag/5-10 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method X Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. / <br />Application Accepted By <br />Grout Inspection By <br />Pump inspection By <br />Soil Boring Inspection By <br />COMMENTS <a <br />CE NOjjCE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />—�/ TITLE Owner/Operator DATE 03/14/18 <br />PAR MENT U E O Y <br />tDate fl�Area Employee I <br />Date PECIAL Well Permit <br />Date (� WAIVER Received <br />', Date Constructed Well Depth <br />PE SC Received Chec Amount Date Permit - <br />Codes Well Codes Info B emitted Service Request # <br />0 3 i D3 <br />ft <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />_y <br />r� <br />D <br />z <br />m <br />N <br />Receive,) <br />F Y41ENT <br />Ce jve,) <br />MAR 19 2018 <br />JOAQU/ly C <br />lV/R p OUM <br />THD PAR MENTM <br />