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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 /> g <br /> JOB ADDRESS a <br /> 2510 S.ST RT 99 W Fronto Road CITY/ZIP Stockton/95205 0 <br /> Mariposa Road 17130024 <br /> CROSS STREET P APN PARCEL SIZE 2.0 aC. LAND USE APPLICATION# o <br /> z <br /> OWNER NAME The James E. Blincoe Separate Property Trust PHONE n/a H <br /> OWNER ADDRESS 14501 Wells Lane CITY/STATE/LP Lodi/CA/95240 <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 Salem Engineering Group, Inc. PHONE 559-271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 W Jacquelyn Avenue CITY/STATE/LP Fresno/CA/93722 <br /> M <br /> LICENSE C-57 ;:I C-61 I:D-09 it Other NUMBER 97772 EXPIRATION DATE 3/31/2020 <br /> DOMESTIC WELL SAMPLING:f 1 General Mineral/Coliform Bacteria(4391)i Dlbromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED U -1 Domestic/Private - Irrigation/Agricultural Industrial 1-1 Water Quality Monitoring VSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 New Well I Replacement Well I. Well Alteration/Modification [1 Other <br /> 1 Monitoring Well(s) #of wells I1 Soil Boring(s) #of borings VGeotechnical 2 #of borings <br /> _i Out-Of-Service Well 0 Out-Of-Service Well Renewal Li Cross-Connection Repair <br /> [I New Pum 1 Pump Replacement i I Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary VAuger I I Cable Tool C1 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter -11 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> -'1 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_��inn T�hicckkness/Gauge/ASTM Sched -i Steel U Plastic a Stainless Steel -iOther <br /> ��F� <br /> Grout Seal Depth; d"f ✓Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) a Other <br /> Grout Placement Method 'I Pumped 1✓Free Fall �Other Tremie Pipe I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ]Pump Contractor ❑ Other <br /> u Concrete Pedestal[]Dimensions:Width ft Length It Thick in IJ Christy Box ❑Stove Pipe <br /> PUMP r Submersible❑Turbine ❑Other HP Pump Set It 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED '/hx t belch TITLE Geotechnical Project Engineer DATE 10/7/2019 <br /> R qYM <br /> Fp <br /> or <br /> OF gRFT q�N� <br /> �fFNT <br /> PA TMENT USE O LY <br /> Application Accepted By ate_4ha'F Area Employee ID# <br /> Grout Inspection By Date ���� SPECIAL Well Permit <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil Boring Inspection Byy ' Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Che Amount PermiU <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />