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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTuENT 1363 EAST HAZELTON AvENur-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Lo <br /> JOB ADDRESS 5365 Arch Road crrymP Stockton,CA 95215_ <br /> D <br /> CROsSSTREEr Newcastle Road APN 181-100-15 - - PARCELSa %.1-Z.UsE APPUCATION- o <br /> r 07e�t— LI/(/�) <br /> OWNER NAME CT Real' PHONE (949)431$400 <br /> OWNER ADDREss _ 4343 Von Karman Avenue,Suite 200 CrryySTATEmP Newport Beach,CA 92660 <br /> CONTRACTORH1 Drilling Company PHONE (916)281-4558 <br /> CONTRACTOR ADDRESS. 9451 Linda Rio Drive crrY1STATEZP Sacramento.CA 95827 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATFJhP <br /> LICENSE X C-57 :.C-61 ':D-09 "Other NumaER 1006095 E.MRAnON DATE <br /> DomEsne WELL SAMPLING: :General Mineral/Coliform Bacteria(4391):-Dibromochloropropane(4392) Arsenic(4393) <br /> ----- ------- <br /> INTENDED UsE DomestictPrivate 7 Irriga0ordAgrirultural Industrial ::Water Quality Monitoring X Soil SampGnglCharacterizatien <br /> Public Water System <br /> If 6tic rd ft=Owe. LVrter Sys7em Name CpCad Name ar Phi N.m <br /> TYPE OF WORK New Well . Replacement Well C Well Alteration/Modification Other <br /> Monitoring Woll(s) Y of walls ❑Soil Bonng(s) s o2bo""9' a Geotechnical 5 a°rto""u, <br /> Out-Of-Service Well Cl Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ __ New Pump Pump Replacement I I Pump Repair Raise Well Casing <br /> C <br /> rWELL ONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 20'3° it Excavation in diameter ::Open Bottom ::Gravel Pack/Gravel Size in diametor <br /> Conductor Casing in diameter y Conductor Casing Depth it <br /> We11 Casing Diameter_in Thickness(Gauge/ASTM Sc hed Steel Plastic Stainless 5teei : Other <br /> Grout Seal Depth 20-3 a ft X Neal Cement(94 lb bag/5-10 gat w3tor) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ::Pumped i I Free Fad Ther i I Retardant/Accelerator(name) <br /> PEDESTAL Installed By G Driller ::Pump Contractor :: Other <br /> Concrete Pedestal Dimensions.Width ft Length ft Thick in .Christy Box Stove Pipe <br /> �ilxa Submersible::Turbine _.Otho HP Pump Sat ft Standing Water Level It <br /> I HEREBY CERTIFY THAT t 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. 1 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 CO BASION LAS�/5. <br /> ! dI' UN'46 H ADVANCE NC7iC=REGU7R FOR INS_PECTIONTS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �`—U DATE I. <br /> _ <br /> XOle <br /> " I <br /> �- 1 - - - - - <br /> P4 TUENT U E O//ymm J- , ok" <br /> LY rq/ <br /> Application Accepted By ate Area Employee IDR (�1I Y <br /> Grout Inspection By Date3r;'/2-W&e SPECIAL Well PefTnit <br /> Pump inspection By Date .. WAIVER Received <br /> Soil Boring Inspection By Data Constnrcted Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well 1139 <br /> Codes Info B e ce Request# <br /> _ T � <br /> a! <br /> EHD43-W­+-dUt4r18 M tl1?VR:4'Pl H0.11r <br />