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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />n L1n-KEFUINDA5LE rFRMIT (;ALL (ZUV) V53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2111 Ouail Lakes Drive CITY/ZIP Stockton 95207 <br />CROSS STREET Alexandria Place APN 108-020-04 PARCEL SIZE 6.01 LAND USE APPLICATION # <br />OWNER NAME Stockton Unified School District - Mr. Christopher Beamon PHONE 209.933.7045. Ext. 2342 <br />OWNER ADDRESS 1944 North EI Pinal CITY/STATE/ZIP 95205 <br />CONTRACTOR West Coast Exploration - Andrew Hernandez, Owner/Operator PHONE 209.838.1723 <br />CONTRACTOR ADDRESS P.O. Box 133 CITY/STATE/ZIP Escalon, CA 95320 <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER .870761 EXPIRATION <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 tsystern Name UontaCt Nam or Phone N.Mbe, <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) # of °onngs X Geotechnical 7 # of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 10 to 20 it Excavation 4 1/2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ inThicknes /Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depthfull depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />(��0=��^lids) Other <br />Grout 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 ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />1 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 />_T <br />M <br />D <br />0 <br />A <br />m <br />N <br />o! <br />Application Accepted By <br />PA TMENT U E O Y1 <br />Date <br />- 3Area Employee ID# <br />41% 01 I S S <br />Grout Inspection By <br />Date <br />4 <br />PECIAL Well Permit <br />Pump Inspection By <br />Date <br />WAIVER Received <br />Soil Boning Ins <br />g P ���'V�. <br />/Date <br />Constr cteQ Depth <br />ft <br />COMMENTS <br />P lg c ` p P7/J,15C <br />old/ <br />cWell <br />-Auk <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount <br />Remitted Date <br />Permit/ <br />Service Re uest# Invoice# WellID# <br />41% 01 I S S <br />-3w. <br />IUP U 0 3 9 <br />hHU as -M WELL /PUMP PERMIT <br />4/30112 <br />