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c � <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> NON-REFUNDABLE PERMIT www-sjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3988 Plymouth Rd CmdLP Stockton,CA,95204 mD <br /> CROSS STREET River Dr APN 11102001 .-RCEL SIZIL acres LAND USE APPLICATION# A <br /> Cristobal Rosete <br /> (661)599-7003 y <br /> OWNER NAME PHONE <br /> OWNER ADDRESS 1505 East Sonora Street CrTYISTATEMP Stockton,CA 95205 <br /> W <br /> Cotton,Shires and Associates,Inc. PHONE (408)354-5542 00 <br /> CONTRACTOR <br /> 00 <br /> CONTRACTOR ADDRESS 330 Village Lane CITYISTATEIZIP Los Gatos,CA,95030 <br /> SUBCONTRACTORICONSULTANT West Coast-Brill-v VI I In(,. jSPHONE 170"1)q bJ �t5`I O <br /> SUBCONTRACTORICONSULTANT ADDRESS J CITYISTATE/Z1P �-2 <br /> 10 <br /> =rI <br /> �( <br /> LICENSE C-57 C-61 D-09 Other NUMBER I EXPtRA-noN DATE 13 I/00 L2 Q <br /> BILLING PARTY: OWNER ,CONTRACTOR leSUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)_Dtbromachloropropane(4392)U Arsenic(4393) <br /> INTENDED USE Domestic/Private -'IrrigatiordAgricultural I; 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 l? New Well r; Replacement Well - Well Alteration/Modification r-, Other <br /> - Monitoring Well(s) #of wells , Soil Boring(s) #of borings Geotechnical 3 #of borings <br /> Out-Of-Service Well - Out-Of-Service Well Renewal ':Cross-Connection Repair <br /> New Pump Pump Replacement i Pump Repair :I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -. Mud Rotary Air Rotary 'A-uger Cable Tool Push Point 7 Other <br /> Proposed Well Depth ft Excavation in diameter _I Open Bottom n Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thicknes%Gauge/ASTM Sched I Steel _ Plastic Stainless Steel 1 Other <br /> Grout Seal Depth s-0a ft VNeat Cement(94 lb bag/5-10 gal/mater) Sand Cement sack mirl7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method i• Pumped n Free Fall C Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller C Pump Contractor I', Other <br /> Concrete Pedestal l Dimensions:Width ft Length ft Thick in .:Christy Box F; Stove Pipe <br /> PUMP Submersible ' Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 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 148 HO DVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ' -PLEASE CALL(209)953-7697 <br /> SIGNED / TITLE / e�� I V�"ly� DATE 0& / Z 2•U LD <br /> v <br /> SEE LOCATION MAP ON PAGE 3 <br /> NT <br /> 0 <br /> A <br /> AL t�R Afn Cp <br /> MFNT <br /> DEPARTMENT USE ONLY �} <br /> Application Accepted By C�l� Z-- Date � /S" 0,2 b Area C Employee ID# D/ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By� Date ct/ Constructed Weil Depth ft <br /> COMMENTS G! in o w, tSF,,bnG + ,fif� 1 h tie lid 'brIF i 7 iahibr�P�� <br /> n6s ah, P ell to b- spoled Itslr / n 17 re rhe i"h"WO IS 6yet 36 Feet r» cyp'n a <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Em Ca h Remitted Service Request# <br /> `1374 Is a 476n (lIlc -n KIP 0A 080 <br /> EHD 43-06 6/11/2019 /O�//LL/ Q�� WELL/PUMP PERMIT <br />