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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 821 W.8th Street&715 W.8th Street CITY/ZIP Stockton,CA 95206 m <br /> D <br /> Lever Boulevard PARCEL SIZE SLAND USE APPLICATION# z <br /> CROSS STREET APN163-14-012;163-14-013:163-14-014 17.3 acre <br /> m <br /> OWNER NAME Stockton 1313 Petroleum Inc PHONE <br /> OWNER ADDRESS P.O. Box 3820 CITY/STATE/ZIP Turlock,CA 95381 <br /> CONTRACTOR Exploration Geoservices,Inc PHONE 408-280-6822 <br /> CONTRACTOR ADDRESS 1535 Industrial Avenue CITY/STATE/ZIP San Jose,CA 95112 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE PJ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 484288 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Z 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 Z Soil Boring(s) #of borings g Geotechnical #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 ❑ Mud Rotary ❑ Air Rotary A Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 15 to 30 ft Excavation 8 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 H Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 2j Other Borings will be grouted per San Joaquin County guidelines <br /> Grout Placement Method ❑ Pumped Z Free Fall s Other Tremie(if needed) ❑ Retardant/Accelerator(name) <br /> IPEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> F1 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, STAT LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT D ACTNE WIT HE IF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO ATION S. <br /> MINIMU A V CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE President DATE 11/14/18 <br /> r <br /> ✓0 <br /> p F h <br /> F <br /> Dr= P RTMENT U E ONLY <br /> Application Accepted By Date C Area. Employee ID# <br /> Grout Inspection By i Date SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS I 2I2 1 i !.9 <br /> PE SC Received Chec Amount Date PermiU Invoice# Well ID# <br /> Codes Info B ash Re itted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />