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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.org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> 5� a113 Keene GLk <br /> Joe ADDRESS see plan sheet t CITY/ZIP 95220 re <br /> CROSS STREET Liberty Road APN N/A in county ROW PARCEL SIZE N/A LAND USE APPLICATION#N/A <br /> re <br /> OWNER NAME San Joaquin County PHONE N/A in <br /> OWNER ADDRESS 1868 East Hazelton Avenue CRY/STATE/ZIP Stockton <br /> CONTRACTOR MGE PHONE 916-421-1000 <br /> CONTRACTOR ADDRESS 7415 Greenhaven Drive,Suite 100 CITY/STATE/ZIP Sacramento,CA 95831 <br /> SUBCONTRACTOR/CONSULTANT Geo-Ex PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1510 Madera Ddve CITY/STATE/ZIP Dixon,CA 95620 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 954267 EXPIRATION DATE 07/30/20 <br /> BILLING PARTY: OWNER CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <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 Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) u of bonngs X Geotechnical 2 a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary Air Rotary Auger 'Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation 4-6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing N/A in diameter / Conductor Casing Depth N/A ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel 1 Other <br /> Grout Seal Depth 20 ft Neal Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fail Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box 1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Senior Project Manager DATE 3 March 2020 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area EmployeeID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />