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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 /> JOB ADDRESS 1725 Turnpike Road L �I'C�nc{� l�lA',.I:_,_ ,TY/ZJP Stockton/ 95206 m <br /> D <br /> CROSS STREET West 4th Street APN 165-040-210 PARCEL SIZE 1.09Acre LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Tony Khatirine PHONE 209-368-8100 N <br /> OWNER ADDRESS P.O.Box 2695 CITY/STATE/ZIP Lodi/CA/95241 <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.DBA Salem Well Drilling PHONE 559-271-9700 <br /> SUBCONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> LICENSE C-57 L C-61 D-09 Other NUMBER 970772 EXPIRATION DATE 3/31/2020 <br /> Do Tic WELL SAMPLING:I;General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private F',Irrigation/Agricultural Industrial Water Quality Monitoring Vs,oil Sampling/Charactenzabon <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well Replacement Well Ci Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells C Soil Bonng(s) #of bonngs Geotechnical 4 #of borings <br /> 11 Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> I New Pump D Pump Replacement E Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary D Air Rotary Auger I Cable Tool ❑Push Point ❑ Other <br /> Prosed Well Depth ` 3 5 ft Excavation in diameter Fl Open Bottom LI Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> VX Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic i Stainless Steel i i Other <br /> Grout Seal Depth :, - ft Neat Cement(94 lb bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method I Pumped I1 Free Fall N Other Tremie Pipe Retardant/Accelerator(name) <br /> PEbdTAL Installed By '7 Driller Ll Pump Contractor Other <br /> ❑Concrete Pedestal i7Dimensions:Width It Length ft Thick in Christy Box -'.Stove Pipe <br /> P P ❑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 /> (M�/,IINIMU9M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED acw �EICh TITLE Project Geotechnical Engineer DATE 3/20/2020 <br /> E�MFi�T <br /> IL <br /> F��FO <br /> " ?6 13000 <br /> pq R Cou�TY <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ? � �� .t Date G -0 ,0 Area :.f'e �''' Employee ID# <br /> Grout Inspection By Date 14 L 'C <br /> SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ?!; Ytt .1Tof (ie ah f.:FCJ {cir 3 0 c -mFIe y,/r .t r <br /> /Tar 79T � <br /> PE Sc Received ,-`ChecW Amount Date Permit] Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> ISO 14V— <br /> EHD 43-06 revised 4114/18 WELL(PUMP PERMIT <br />