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`r <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 /> ro <br /> JOB ADDRESS 3764 Portage Plaza CITY/zIP Stockton 95219 <br /> D <br /> CROSS STREET Portage APN 098-50-012 PARCEL SIZE •43 LAND USE APPLICATION# S <br /> Gong m <br /> Ed G <br /> OWNER NAME 9 PHONE w <br /> OWNER ADDRESS 3764 Portage Plaza CITY/STATE/ZIP Stockton,Ca 95219 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT West Coast Exploration, Inc PHONE 209.985.7541 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS PO Box 133 CITY/STATE/LP Escalon,CA 95320 <br /> LICENSE X C-57 ❑C-61 D-09 `:'.Other NUMBER 870761 EXPIRATION DATE 1/31/2022 <br /> BILLING PARTY: L OWNER _ CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural -i Industrial Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System Andrew Hernandez 209.985.7541 <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 X Soil Borings) 2 #of borings X Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> ❑New Pum _1 Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 'i Mud Rotary Li Air Rotary ❑Auger n Cable Tool ❑Push Point Other <br /> Proposed Well Depth 18 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> i l Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth -18 ft V Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ;Pumped ❑Free Fall 3L Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By F-1 Driller ❑Pump Contractor ❑ Other <br /> L1 Concrete Pedestal LIDimensions:Width ft Length ft Thick in ❑Christy Box F Stove Pipe <br /> PUMP I SUbmersibler!Turbine ❑Other HP Pump Set it 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 Andrew Hernandez TITLE President DATE 5/14/2020 <br /> C7- <br /> F� FD <br /> l g A?020 <br /> 41 C <br /> ri <br /> D pq R�ME1 0Y <br /> �J LDEPARTMENT USE ONLY <br /> Application Accepted By ` /v Date S $� Zai Area Employee ID# IDA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By f Date WAIVER Received <br /> Soil Boring Inspection By f'r&'-w W Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 8 Cas Remitted S ice a ues <br /> 376t 5 0 •� <br /> EHD 43-06 81112019 )V'?�Z3 WELL/PUMP PERMIT <br />