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it <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/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 10880 N 99 Frontage Road c,TYizIP Stockton,95212 m <br /> a <br /> CROSSSTREET Eight Mile Road APN 08607046 PARCELSIZE 1.05 LAND USE APPLICATION# z <br /> m <br /> OWNER NAME Ash rafAli PHONE 707-747-2955 <br /> OWNER ADDRESS 5000 East 2nd Street,Suite G CITY/STATEZP Benicia/California/94510 <br /> 00 <br /> Co <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> Z <br /> CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATEZP Fresno,California 93722 <br /> SUBCONTRACTOR/CONSULTANT Salem Engineering Group.Inc. PHONE 559-271-9700 <br /> O <br /> ° <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4729 West Jacquelyn Avenue CITYISTATEZFresno,California 93722 <br /> P p1 <br /> LICENSE V C-57 C-61 D-09 Other NUMBER 970772 ExPIRATION DATE 3/31/2020 <br /> BILLING PARTY: OWNER CONTRACTOR V SUBCONTRACTOR/CONSULTANT P- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)� Arsenic(4393) :n <br /> INTENDED USE Domestic/Private 1 Irrigation/Agricultural Industrial Water Quality Monitoring V Soil Sampling/Characterization <br /> Public Water System p <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification Other <br /> N <br /> Monitoring Well(s) #of wells 1 Soil Boring(s) #of bonngs it Geotechnical three #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casingy <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary 1 Auger Cable Tool Push Point i Other <br /> Proposed Well Depths ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel i Plastic i Stainless Steel i Other <br /> Grout Seal Depth 5 tO 50 ft o Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method i Pumped d Free Fall V Other Tremmle Retardant/Accelerator(name) <br /> PEDESTAL Installed By ' Driller I Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP i Submersible Turbine 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 1 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 Geotechnical Staff Engineer DATE 6/2/2020 <br /> Y <br /> FMFNr <br /> SFO <br /> ?AZO <br /> r qo. 'y <br /> MFA( <br /> DEPARTMENT UY <br /> Application Accepted By��v� Date Area q EmployeelD#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Recelved <br /> Soil Boring Inspection By i 1 1. f.SCD nt �.,iz Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received k.Qheck#V Amount Da Permly Invoice# Well ID# <br /> Codes Info Remitted ervice Re u st# <br /> 7 s"D - <br /> EHD43-06 6/1112019 WELL/PUMP PERMIT <br />