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WELL/PUMP PERMIT <br /> SAN JOACUW CouNTY Ewm*mENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AvENuE-STocKToN CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS r9cEXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Jos ADDRESS Miner Avenue rnr P Stockton, CA 95202 m <br /> CROSS STREET Center St/Aurora S D <br /> tJ1PN n/a PARCEL SIZE LAND USE APPLICATION# o <br /> z <br /> OWNER NAME City Of Stockton PHONE <br /> OWNER ADDRESS Crry/STATEMP <br /> CONTRACTOR BSK Associates (consultant) PHONE 916.853.9293 <br /> CoNTRACTORADDREss 3140 Gold Carl Drive #160 crrdsTATEmpRancho Cordova, CA 95670 <br /> SUBCONTRACTOR Dave's Drilling PHONE 559.999.2603 <br /> SUBCONTRACTORADDRESs 5830 W. Fir Ave. 1ccrrr/sTATEmP Fresno, CA 93722 <br /> LICENSE X C-57 C-61 C D-09 2 Other NUMBER T'J E"iPATIDN DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochioropropane(4392)C Arsenic(4393) <br /> INTENDED USE DomesticlPrivate l Irrigation/Agricultural ❑Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> r Public Water System <br /> H dBerent horn Owner: Water System Name Conrad Name or Phone Nranber <br /> TYPE OF WORK 7 New Well :i Replacement Well i!Well Alteration/ModifiCation !i Other <br /> ❑Monitoring Well(s) #of wells L'Soil Boring(s) xofbnnegs 2Geotechnical 7 4ofborings <br /> 0 Out-Of-Service Well i Out-Of-Service Well Renewal t:Cross-Connection Repair <br /> ❑New Pump Ci Pump Replacement a Pump Repair !Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary I Air Rotary tXAuger i Cable Tool I Push Point i i Other <br /> Proposed Well Depth 10-15' ft Excavation 8 in diameter G Open Bottom O Gravel Pack/Gravel Size in diameter <br /> 1 i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Sched a Steel L i Plastic C Stainless Steel G Other <br /> Grout Seal Depth 10-151 It k Neat Cement(94/b ba9/5-10 gal water) Sand Cement sack mixll gal water <br /> F1 Bentonite(20%solids) I Other Ar_ <br /> Grout Placement Method !I Pumped X Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1Driller I I Pump Contractor r Other <br /> Concrete Pedestal-iDimensions:Width it Length ft Thick in i Christy Box C Stove Pipe <br /> PUMP 7 Submersiblei.l Turbine 1.1 Other HP Pump Set It Standing Water Level ft ��®V f �+ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANS, / Q 2018 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS 1V,/0 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL ENV AQUI4,Cp <br /> WORKERS COMPENSATION S. H RpNMF UN7y <br /> MINIMUtr1 riOU A�11E UIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697/�j LTN UEPAR MENT <br /> SIGNED TITLE_ A/A e r DATE 1 -I 7 -/- <br /> TITLE <br /> EIV <br /> �iI® <br /> ov <br /> ap <br /> 15 2018 <br /> MENTALHEALTH <br /> MIT/SERVICES <br /> 1# - 111T <br /> �,PA.�R/MENZIZEA"�6Date <br /> Y <br /> Application Accepted By Area_//i Employee ID#Grout Inspection By O SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER ReeelVed <br /> Soil BoringI&pection B �D <br /> Da � Constructed Well Depth /�� It ,Q <br /> COMMENTS s . f�rLCS��I! <br /> PE Sc Received Check#/ Amount Date PermiU Invoice# Well IDM <br /> Codes Info B ash Remitted Service Request# <br /> 97f- <br /> EHD 43-06 revised 4!14/18 �� WELL/PUMP PERMn <br />