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19525 <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 /> JOB ADDRESS 1728 EI Camino Ave CITYIZIP Stockton,CA 95209 <br /> D <br /> CROSS STREET Balboa Ave APN 075-140-560 PARCEL SIZE 2.12 ac LAND USE APPLICATION# <br /> m <br /> OWNER NAME Sims-Grupe Management PHONE e! <br /> OWNER ADDRESS 1728 EI Camino Ave CITYISTATE/ZIP Stockton,CA 95209 <br /> CONTRACTOR Eaton Pumps Sales&Service PHONE 530-661-6737 <br /> CONTRACTOR ADDRESS 10 W Kentucky Ave CITY/STATE/ZIP Woodland,CA 95695 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE E C-57 0 C-61 ❑D-09 0 Other NUMBER 133783 EXPIRATION DATE 07/31/2020 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If ddferenl from Owner, Weler System Nem. Contact Name or Phone Number <br /> TYPE OF WORK Di New Well ❑Replacement Well 0 Well Alteration/Modification ■Other Pull Pump for Well Video Survey <br /> 0 Monitoring Well(s) #of wells ❑Sall Boring(s) 0 ofbodnas 0 Geolechnical 0 of borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft D Neal Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 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, 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 HOUR ADV NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-776697 <br /> SIGNED ---7/1 <br /> TITLE Authorized Agent DATE ey(Q <br /> J <br /> A(Z o <br /> IKLAkMc D.-!SV A2 <br /> ✓ogQ�1? X419 <br /> Ro N <br /> FNT <br /> TMENT U E O LY <br /> Application Accepted By <br /> ate Area EmployeeID#_ tet`-- <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By o LludaalwDate ❑ WAIVER Received <br /> Soil Boring Ins <br /> p <br /> ection BDale Constructed Well Depth ft <br /> COMMENTS / W <br /> PE SC 1 Received eCIFe Amount Permit/ <br /> o s Info B ash emitted / Date Service Re uest# Invoice# Well Ili <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />