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i <br /> ,r 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 1 YEAR FROM DATE ISSUED <br /> 12271 W. Bethany Rd Tracy/95376 <br /> JOB ADDRESS Y CITY/ZIP T /95376 Y <br /> D <br /> CROSS STREET Corral Hollow Rd. APN 212-090-08 PARCEL SIZE 9.7 ACresLAND USE APPLICATION# a <br /> m <br /> OWNER NAME Eva Naverette PHONE in <br /> OWNER ADDRESS 12271 W.Bethany Rd CITY/STATECZIP Tracy/CA/95376 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATEZP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL,INC. PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave,Suite 150 CITY/STATEZP MODESTO/CA/95356 <br /> LICENSE k C-57 I C-61 CI D-09 Cl Other NUMBER 870761 EXPIRATION DATE 01/31/2022 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR Q SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE :Domestic/Private _ Irrigation/Agricultural Industrial Water Quality Monitoring 9 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 U Well Alteration/Modification ❑Other <br /> i Monitoring Well(s) #of wells U Soil Boring(s) #of borings x Geotechnical 1 e of borings <br /> i I Out-Of-Service Well U Out-Of-Service Well Renewal n Cross-Connection Repair <br /> New Pum L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary Air Rotary w Auger ❑Cable Tool n Push Point n Other <br /> Proposed Well Depth 15 ft Excavation 4 in diameter i'Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel ❑Plastic Stainless Steel U Other <br /> Grout Seal Depth ft x Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> I I Bentonite(20%solids) 11 Other <br /> Grout Placement Method L.Pumped x Free Fall a Other i.Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor IOther <br /> Ll Concrete Pedestal LDimensions:VVidth ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP i Submersible_Turbine j Other HP Pump Set ft Standing Water Level ft <br /> 1 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 lea4- TITLE Staff Geologist DATE 5/1/2020 <br /> S E E AIT T A C H E D <br /> EANT <br /> Ep <br /> A 4 2020 <br /> L A NTq�TY <br /> RTI�ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date S y ZQ�ro Area Employee ID# bA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring Inspection Date 2f�� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit! Invoice Well ID# <br /> Codes Info as Remitted rvice Re ueSt# <br /> 37d so .sem s <br /> EHD43-06 6/112019 WELL/PUMP PERMIT <br />