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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 /> rA <br /> JOB ADDRESS 3601 Pacific Avenue CITY/ZIP Stockton/95211 <br /> a <br /> CROSS STREET Dave BrUbeCk Way APN 11314013 and 11314002 PARCEL SIZE 152.9 Acres LAND USE APPLICATION# o <br /> M <br /> OWNER NAME University of the Pacific PHONE 209-946-2285 <br /> OWNER ADDRESS 3601 Pacific Avenue CITY/STATE/ZIP Stockton/CA/95211 <br /> CONTRACTOR Salem Engineering Group, Inc. PHONE (559)271-9700 <br /> CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITYISTATE21P Fresno/CA/93722 <br /> SUBCONTRACTOR Salem Engineering Group, Inc. PHONE (559)271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITYISTATE/ZIP Fresno/CA/93722 <br /> LICENSE k C-57 i C-61 1 D-09 I Other NUMBER 970772 EXPIRATION DATE 3/3112020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural i Industrial Water Quality Monitoring I Soil Sampling/Charactenzalion <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 /> i Monitoring Well(s) #of wells X Soil Bonng(s) 28 If of borings X Geotechnical 28 #of Wings <br /> Out-Of-Service Well Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary x Auger Cable Tool Push Point I I Other <br /> Proposed Well Depth 15-25 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel i Plastic i Stainless Steel I Other <br /> Grout Seal Depth 15-25 ft x Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method 1 Pumped.M.Wfoo-Pell Other- I 1 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 Submersibles Turbine � Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAV PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUN RDINANCE STATE LAWS, A RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN ACTT E WI H T E C LIF RNIA TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C MPENS TI L <br /> M IMUM R V REQUIRED FOR INSPECTIONS <br /> _-nPLEASE CALL(20V953- 697 <br /> SIGNED TITLE �'7a/t DATE <br /> YMFl <br /> !IVFDN <br /> ?y 2018 <br /> /N <br /> I MF <br /> R <br /> OUIVTY <br /> AMFNT <br /> PA MENT U E O LY �'/�L <br /> Application Accepted By to S tv Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date � Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Se ice Re uest# <br /> i <br /> EHD 43-06 revised 4114118 WELL/PUMP PERMIT <br />