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WELL/PUMP PERMIT <br /> S/N 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 /> Ln <br /> JOB ADDRESS 821 W.8th Street&715 W.8th Street CITY/ZIP Stockton, CA 95206 m <br /> D <br /> Lever Boulevard + (;i' <br /> A <br /> CROSS STREET APN 163-14-012 R �i-1 +— PRCEL SIZE 8.8 acres LAND USE APPLICATION# <br /> M <br /> OWNER NAME Stockton 1313 Petroleum IncPHONE <br /> OWNER ADDRESS P.O. BOX 3820 CITY/STATE/ZIP Turlock,CA 95381 <br /> CONTRACTOR Middle Earth Geo Testing, Inc PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 95544 N Lemon Street CITY/STATE/ZIP Orange, CA 92867 <br /> SUBCONTRACTOR ��% t �A V C — � � �� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 7 C-57 C-61 D-09 Other NUMBER 899451 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Fl Irrigation/Agricultural Industrial ❑ Water Quality Monitoring / Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells / Soil Boring(s) #of borings / Geotechnical 2 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method G Mud Rotary Air Rotary Auger Cable Tool / Push Point Other <br /> Proposed Well Depth 50-100 ft Excavation 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft B Neat Cement(94/b bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other CPT will be grouted per San Joaquin County guidelines <br /> Grout Placement Method Pumped H Free Fall 7 Other Tremie(if needed) 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 /> 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED 4. TITLE DATE <br /> ee s L� <br /> tt C <br /> R A dT <br /> ',Qee l6extpadeo icaln tL r <br /> n F p A r T M F N T I IC Q N I Y <br /> Application Accepted By Date Area L Employee ID##A% �/ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date 12 l-�i 1 Constructed Well Depth ftp <br /> COMMENTS 3�G( <br /> PE Sc Received hec Amount Permit/ <br /> Codes Info B emitted— Date Service Request# Invoice# Well ID# <br /> EH 43-06 revised 4/14118 WELL/PUMP PERMIT <br />