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WELL/PUMP PERMIT <br /> SAN JoAcLoN CouHrrY EwimwrENTAL HEALTH DEPARTMENT 1869 EAST HAzELTON AvENUE-STocum CA 90205 8232(209)468-WO <br /> NONREFUNDABLE PERMIT wwwAgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe App, Pezzi Road at Calaveras River Bridge Crymp Stockton <br /> CPO"STWXTComstock Rd (near) Am N/A PARCEL$ME LAm UsE APPIICATON# <br /> OWNERNAYE San Joaquin County Public Works PSE 209-468-3000 <br /> OMERAoORm 1810 East Hazelton Avenue CrrYMTATFlbv Stockton, CA <br /> CONTRACTOR Geocon Consultants, Inc. PHONE <br /> CONTRACTOR A. 3160 Gold Valley Drive, Sutie 800 CrffMATFJZ. Rancho Cordova, CA 95742 <br /> SUBCONTRAOToaCONSULTANr Taber Drilling PHM916-371-8234 <br /> SuecoKn;u=roRlCoxsuLTANr ADORE= 536 Galveston St Cm,MAMMP W. Sacramento, CA 95691 <br /> LicemE XI C57 ❑C61 ❑D-09 ❑Other NumsER 969927 ExpstATtoN DATE 02.29.2020 <br /> BLuma PARTY: ❑OWNER D CONTRACTOR n SUBCONTRACTOR/CONSULTANT <br /> DOMEIMC WELL SAMPIRHO:❑General Mlneral/ColdorTn Bacteria(4391) Dibromochloropropane(4392)❑Arsenic(4393) <br /> IwTENom UEE ❑Dom WPdvate ❑ImfgationlAgrlcuttural ❑Industrial n Water Quality Monttortrg (R Sou SampIkWCharscterization <br /> ❑Public Water System <br /> R dllwerd from Orate Water Syrsn Name Contact Nana or Ptwne Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlteretionlModlRcation ❑Other <br /> ❑Monitoring Well(s) #of web R SON Borg(s) 1 p dtotnga ❑Geotechnical edtaM�ps <br /> ❑Out-Of-Service Well ❑Out-OVService Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well CashV <br /> WELL C.ONgTRUCT10N <br /> Drilling Method ❑Mud Rotary ❑Air Rotary a Auger ❑Cade Tod ❑Push Point ❑ Other <br /> Proposed Well Depth 90 it Excavation In diameter ❑Open Bottom n Gravel Pack/Gravel Size In diameter <br /> a Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In ThicknesslGeuge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel i i Other <br /> Grout Seal Depth 9() ft X Neat Cement(94 D beg,5-10 gal water) ❑Sand Cement sack mlxl7 gal water <br /> ❑Bentonite(20%sollda) ❑Other <br /> Grout Placoment Method Pumped ❑Free Fall ❑ �A40� E Retardant I Accelerator(name) <br /> PP.DE6TAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete PedesW❑Dirrmulons:Width ft Length ft Thidt In ❑Christy Boz ❑Stove Pipe <br /> PUMP n Submerslde❑Turbine D Other HP Pune Set It 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI UR VANCE NOJICE REQUIRED FO`Rr IN PECT 9N P SEYALL(209)953-7�6/97� <br /> St TRIS V f �l�P DATE 1b. 1Y/1 <br /> IIIII Jill Hill <br /> Hill Jill Hill I III IIII Jill <br /> Hill 1 11 11 1 1 IL Jill <br /> PAYIW EIVr <br /> Hill 1 11 1 <br /> Hill I III III <br /> I SAN <br /> ENVOIRONME®UN7-), <br /> LTII DEPARTMENT <br /> t;AtM EbN TLYApplication Accepted By ` Puss [ i Employee ID# <br /> Grout Inspection By Date Fl SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Baring Inspection By /i Bats Constructed Well Depth R <br /> COMMENTS _ <br /> PE SC Recelved Check* Amount Dab PermW Invoice 0 Well Hm <br /> Codeskilo Cash Service Request0 <br /> Ertma.ae e11112019 �� /��^ /� WELL!PUMP PERMfT <br />