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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUIWKE:FUNUALiLt YtKMI I GALL LUy Ub3-tbB! FOR INSPECTIONS LAPIKLS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2910 Eight Mile Road CITY/ZIP Stockton / 95212 <br />CROSS STREET Thornton Road APN 070-670-01 PARCELSIZE 10.09 LAND USE APPLICATION # <br />OWNER NAME .Jiminp..7-Thnrntnn Ron PHONE <br />OWNER ADDRESS PO Box 965 CITY/STATE/ZJP Lodi, CA 95241 <br />CONTRACTOR Salem Engineering Group, Inc. PHONE 559-271-9700 <br />CONTRACTOR ADDRESS 4729 W. Jacquelyn Avenue CITY/STATE/zIP Fresno / CA / 93722 <br />SUBCONTRACTOR n/a <br />SUBCONTRACTOR ADDRESS CrTYISTATEZP <br />LICENSE VC -57 L: C-61 D-09 C Other NUMBER 970772 <br />PHONE <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) _ Arsenic (4393) <br />NTENDED USE ❑ DomestictPdvate F IrrigationlAgricultural F] Industrial .. Water Quality Monitoring Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well a Well Alteration/Modification D Other <br />nMonitoring Well(s) #of wells SoilBoring(s) 12 #ofbodngs G(Geolechnical 12 #orbodngs <br />ri Out -Of -Service Well i I Out -Of -Service Well Renewal Cross -Connection Repair <br />C New Pump it Pump Replacement r. Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary `l Air Rotary VAuger , Cable Tool Push Point f Other <br />Proposed Well Depth 5'-50' ft Excavation 4„-8" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />f] Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel Plastic 'f Stainless Steel r Other <br />Grout Seal Depth ft VNeat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />F1 Bentonite (20% solids) D Other <br />Grout Placement Method D Pumped V Free Fall Other tremmie oipe L Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I, Pump Contractor r Other <br />r Concrete Pedestal FIDimensions: Width ft Length ft Thick in F, Christy Box , Stove Pipe <br />PUMP <br />!I Submersible I I 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 />MINIMUM 24 KO4U DV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �-'� - — TITLE Prom Z_'t' (TT;'' t(�Cknjc j R''1f.�/, DATE I21H/.Ao 17 <br />N <br />m <br />D <br />a <br />z <br />N <br />E P A R T M E N T USE ONLY <br />Application Accepted By / °� Date "' ' �'� J Area ] i0 Employee ID# <br />Grout Inspection By Date .) I. SPECIAL Well Permit <br />Pump Inspection By A 4 ADate I_ WAIVER Received <br />Soil Boring Insp ctio`}By Date /Co/nstructed W I Depth ft <br />COMMENT S l 1 h i i ;a%Q h�P r:Z'' / L,.� C T f <br />l�� L' 16r/ GLI (r ✓�iL ;' /2C r tI Lif to j ' 1 <br />P Y SC Received Che <br />Codes Info B <br />Amount <br />Remitted <br />Date Permit/ Invoice# WeIIID# <br />Service Request # <br />—y <br />EH043-06 eN1110 ' Cl�f`�-t- v CY1y�ii-it G- Ck% Cv. I , rl�G�'�YW1�-� Ne l�l"Z r,/VELL,PUMP PERMIT <br />