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M <br /> 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 /> - rn <br /> JOB ADDRESS 751 Brookside Road CITy21P Stockton/95211 <br /> D <br /> CROSS STREET Pacific Avenue APN 11025019 PARCEL SIZE 22.89 Acres LAND USE APPLICATION# O <br /> A <br /> OWNER NAME University of the Pacific PHONE 209-946-2285 w <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 CITY/STATE/ZIP Fresno/CA/93722 <br /> SUBCONTRACTOR Salem Engineering Group, Inc. PHONE (559)271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> LICENSE ki C-57 i C-61 i C-09 I I Other NUMBER 970772 EXPIRATION DATE 3/31/2020 <br /> DOMESTIC WELL SAMPUNG:i I General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)1 1 Arsenic(4393) <br /> INTENDED USE i i DomestictPrivate I i Irrigation/Agricultural I I Industrial 1 1 Water Quality Monitoring i i Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well 'i Well Alteration/Modification i,Other <br /> Monitoring Well(s) #of wells K Soil Boring(s) 13 S of borings X Geotechnical 13 a of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement i i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i 1 Mud Rotary i I Air Rotary M Auger Cable Tool 1 i Push Point i i Other <br /> Proposed Well Depth 15-25 ft Excavation in diameter i i Open Bottom i i Gravel Pack/Gravel Size in diameter <br /> i i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched i I Steel I i Plastic i i Stainless Steel I i Other <br /> Grout Seal Depth 15-25 ft by Neat Cement(94 Ib bag/5-10 gal water) I i Sand Cement sack mix17 gal water <br /> I i Bentonite(20%solids) i i Other <br /> Grout Placement Method I I Pumped-K-FreiI Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Other <br /> I i Concrete Pedestal Dimensions:Width ft Length It Thick in 1 Christy Box i I Stove Pipe <br /> PUMP i Submersible i Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 AN VE WITH CALIFO NIA CONT CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSPEN TION L <br /> Mf <br /> IMUM 8 h AN E E REQUIRED FOR SPE'C,TIIO�NS PLEASE CALL(209)953- 97 <br /> SIGNED TITLE�QA&Aa f„eDATE <br /> CF�VNr <br /> FD <br /> Z y ?418 <br /> pMENr <br /> '4Rrl yFNr <br /> P Q lyMENT U E O �Ce��� <br /> Application Accepted By to IDIZ� Area /r,'YY//�� ..b�JC��JC� Employee ID#���L+� <br /> Grout Inspection By Dale SPECIAL Well <br /> Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cashemitted Service-Re # <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />