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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468)420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10735 Trinity Parkway CITvIZ1P Stockton/95219 y <br /> � <br /> CROSS STREET Scott Creek Drive APN 06602041 PARCEL SIZE 1.0 Ac <br /> LAND USE APPLICATION aK O <br /> OWNER NAME Mike Sater PHONE 909-293-7588 m <br /> OWNER ADDRESS 683 Cliffside Drive CITY/STATE/;0P San Dimas/CA/91773 <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> SUBCONTRACTOR NIA <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE VC-57 : C-61 D-09 I Other NUMBER 970772 EXPIRATION DATE 3/31/2020 <br /> DoMEsnc WELL SAMPLING:: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_1 Arsenic(4393) <br /> INTENDED USE D Domestic/Private Irrigation/Agricultural -1 Industrial I Water Quality Monitoring NFSoil Sampling/Characterization PAY 6` <br /> lo <br /> D Public Water System " <br /> If different from Owner: Water System Name Contact Name or Phone Number i <br /> TYPE OF WORK D New Well :-Replacement Well ❑Well Alteration/Modification :: Other <br /> 0 Monitoring Well(s) *of wells D Soil Boring(s) a of borings Geotechnical x of b°nnps MAY <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal I Cross-Connection Repair H 1 <br /> D New Pump Pump Replacement ❑Pump Repair _Raise Well Casingf'R <br /> WELL CONSTRUCTION QAQUIN <br /> Drilling Method Mud Rotary Air Rotary VAuger D Cable Tool Push Point Other HEA E&V/RoNME O CUNT y <br /> H p AL <br /> Proposed Well Depth 5-50 ft Excavation 4-8 in diameter Open Bottom L Gravel Pack/Gravel Size in diameter EPART�EN7 <br /> Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel 0 Plastic Stainless Steel ' Other <br /> Grout Seal Depth It NfNe.t Cement(94 Ib bagr5-10 gal water) 0 Sand Cement sack mixn gal water <br /> I Bentonite(20%solids i Other <br /> Grout Placement Method L:Pumped Free Fell Other Tremie Pipe 1:Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor I: Other <br /> Concrete Pedestal DDimenslons:Width fl Length It Thick in n Christy Box D Stove Pipe <br /> PUMP Submersible-ITurbine ❑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 H DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED -� I C TITLE Geotechnical Project Engineer DATE 4/30/2019 <br /> A MENTI UE O LY <br /> r <br /> Application Accepted By ale � AreaEmployee ID# U <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received hec Amount Date Permit/ Invoice i! Well ID# <br /> Codes Info Re ed Service Re uest# <br /> cl 1 � <br /> 'M <br /> am <br /> 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />