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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 4343 N Wilson Way CITY/ZIP Stockton/95205 <br /> C m <br /> CROSS STREET L.McAllen Road APN 132-02-022 PARCEL SIZE 4 TJ ace <br /> USE APPLICATION# o <br /> ONMER NAME Blyden L.P.,a California Limited Partnership PHONE 559-269-5155 � <br /> OWNER ADDRESS 2637 W.Lake Van Ness Circle CITYISTATEIZIP Fresno/CA/93711 <br /> CONTRACTOR Salem F.nglneering Group,Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CITYISTATEIZIP Fresno/CA/93722 <br /> SUBCONTRACTORICONSULTANT Salem Engineering Croup,Inc. PHONE 559-271-9700 <br /> SUBCONTRACTORICONSULTANT ADDRESS 4729 W Jacquelyn Avenue CITYISTATEIZIP Fresno/CA/93722 <br /> LICENSE */C-57 D C-61 II D-09 IJ Other NUMBER 970772 EXPIRATION DATE 03/31/2020 <br /> BILLING PARTY: D OWNER I CONTRACTOR 11 SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:I_ General Mineral/Coliform Bacteria(4391)1. Dibromochloropropane(4392)1 Arsenic(4393) <br /> INTENDED USE D Domestic/Private II Irrigation/Agricultural 11 Industrial LI Water Quality Monitoring V Soil Sampling/Characterization <br /> U Public Water System _ <br /> If drfferent from Owner: Water System Name Cwtad Name o-Phone Number <br /> TYPE OF WORK U New Well I I Replacement Well I I Well Afteration/Modification ISI Other <br /> Il Monitoring Well(s)_ #ofwells 11 Soil Boring(s) ftofbonngs yi(Geotechnical 9 sof borings <br /> U Out-Of-Service Well IJ Out-Of-Service Well Renewal I I Cross-Connection Repair Pq <br /> ❑New Pum CI Pum Replacement Il Pump Re air I Raise Well Casing Y�r^� <br /> WELL CONSTRUCTION <br /> Drilling Method U Mud Rotary U Air Rotary .4/Auger I I Cable Tool LI Push Point i I Other <br /> Proposed Well Depth ft Excavation In diameter (I Open Bottom fl Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft G 02 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ I!Steel I I Plastic I I Stainless Steel D Other O'� <br /> Grout Seal Depth ft 4/Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix17 gal <br /> D Bentonite(20%solids) U Other <br /> Grout Placement Method U Pumped VFree Fall V/Other I relnic I;Retardant/Accelerator(name) <br /> PEDESTAL Installed By II Driller I� Pump Contractor II Other <br /> 11 Concrete Pedestal I0imensions.Width It Length ft Thick in I I Christy BOX U Stove Pipe <br /> PUMP G Submersiblel.l Turbine I I 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 /> MI IMMTIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIO S- LEASE CALL(209)`953-7697 <br /> SIGNED TITLE �' DATE ldj <br /> DEPARTMENT U E O LY IF <br /> Application Accepted By Date el A Area Employee ID# <br /> Grout Inspection By Date V I U SPECIAL Well Permit <br /> Pump Inspection By Date 17 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth Ift <br /> COMMENTS <br /> PE SC Received Qllfe5Amount PermiU <br /> Codes Info B Remitted Dat ervice Re uest# Invoice# Well ID# <br /> l <br /> EHO43-06 6/112019 WELL/PUMP PERMIT <br />