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>r <br /> z <br /> 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/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> Joe ADDRESS 901 E.Scotts Ave. CITY/ZIP Stockton,95203 <br /> D <br /> CROSS STREET Aurora St.South APN 15130001 PARCEL SIZE 1.72 ave LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Union Pacific Railroad PHONE 209-546-7288 N <br /> OWNER ADDRESS 1000 E Roth Rd CITY/STATE/LP French Camp,CA 95231 <br /> m <br /> CONTRACTOR _(Consultant)Shannon&Wilson Inc. PHONE 916-438-2311 rn <br /> S <br /> CONTRACTOR ADDRESS 664 West Broadway CITY/STATE/ZIP Glendale,CA 91204 H <br /> D <br /> Taber Drilling .'tee <br /> SUBCONTRACTORICONSULTANT 9 PHONE 916-371-8234 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 536 Galveston St. CITY/STATE/ZIP West Sacramento,CA 95691 <br /> 0 <br /> LICENSE X C-57 _C-61 ❑D-09 C Othe! NUMBER 969927 EXPIRATION DATE <br /> C) <br /> BILLING PARTY: L OWNER X CONTRACTOR -: SUBCONTRACTOR/CONSULTANT D <br /> _ <n <br /> N <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)-1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private Inigation/Agricultural Industrial Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If dfrerent from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK O New Well =:Replacement Well =Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells Soil Bonng(s) #ofb rIn9s X Geotechnical 4 #of lb lrp <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> S New Pump ❑Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method = Mud Rotary _Air Rotary X Auger _Cable Tool _Push Point - Other <br /> Proposed Well Depth 6,10.&16 ft Excavation fi-8„ in diameter _Open Bottom '=Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched -Steel -Plastic -Stainless Steel Other <br /> Grout Seal Depth 6 i(— it Wi Neat Cement(94/b bag/5-10 gal water) -Sand Cement sack mixn gal water <br /> _. Bentonite(20%solids) C Other <br /> Grout Placement Method X Pumped X Free Fall =Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller G Pump Contractor r Other <br /> Concrete Pedestal❑Dimensions:Widlh ft Length R Thick in -Christy Box Stove Pipe <br /> EU—KIP _Submersible!:Turbine C Other HP Pump Set R Standing Water Level R <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 /> MINI HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED v,G TITLE Staff Engineer DATE 5/29/2020 <br /> _ RE YMFNT <br /> cF/QED <br /> a. R pNM�CPUNT <br /> N�EPg R TAF <br /> NT <br /> TP <br /> DEPARTMENT USF ONLY <br /> Application Accepted By �' `' Date��*����✓/...`�j'rJ..✓7 Area �i oN Employee ID# <br /> Grout Inspection By { <br /> Date —/ 4c-1 Lo D SPECIAL Well Permit <br /> Pump Inspection By Date % _ _ WAIVER Received <br /> Sol]Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info esh Remitted 'c equw <br /> J jc: A.�• 14 L J <br /> EMO 4a-06 6/7I2079 � tlo9 WELL/PUMP PERMIT <br />