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1 � 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON AVENUE-STOCKTON CA 96205$232(209)488.3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3482 Carpenter Road � ' CITY/ZIP Stockton.95205 Y) <br /> D <br /> CROSS STREET Pock Lane APN 179-tEtl "Q-000 PARCEL SIZE 4.76 Be LAND USE APPLICATION 4 p <br /> OWNER NAME Estrella L Josc Fanid Limited Partner,hin 1 1 11 Ren Allan Josef PHONE 209-598-2584 a <br /> OWNER ADDRESS 2.182 Carpenter Road CtTYISTATEybP Stockton.CA 95205 <br /> CONTRACTOR Baja Exploration PHONE 760-715.2566 <br /> CONTRACTOR ADDRESS 246 Vista Grande Glen CITYISTATE/ZIP Escondido/CA/92025 <br /> SUBCONTRACTORICONSULTANT NOUrzay GeoleChnica)Services.Inc. PHONE 951-264-9023 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 16817 Rainy Vale A%enuc CITYISTATEIZIP Rkemido.CA 92503 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 604316 EXPIRATION DATE 2/2912020 <br /> BILLING PARTY: OWNER CONTRACTOR ;t SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water duality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> It dif—M hom Owner Water System Name Contact Name a Phone Numtwl <br /> TYPE OF WORK New Well Replacement Well Well AlterauonrModl6cabon Other <br /> Monitoring Wel ts1 0 of"us Sal Boring(s) a 1i l—,,j, X Geotechnical 3 x or eonevs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary `Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10-itT fl Excavation 8" in diameter 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 Other <br /> Grout Seal Depth 20-50' fl X Neal Cement(94 to bag15-10 gal water) Sand Cement sack mix)`7 gal water <br /> Bentontte(20%sohdsl Other <br /> Grout Placement Method Pumped Free Fag X Other Retardant/Accelerator(name) <br /> FPEDEsTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width R Length R Thick in Christy Box Stove Pipe <br /> PUNP Submersible Turbine Other HP Pump Set ft Standing Water Level fl <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. 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 /> &" <br /> MUM 48R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED / A—.)/J //'7— TITLE Owner-Baja Exploration DATE 8/12119 <br /> MENT <br /> EIVED <br /> 16 2019 <br /> OUIN COUNTY <br /> ONMENTAL <br /> DEPARTMENT <br /> D.ew <br /> AR M E N T U O }L^rY / - - ^ <br /> Application Accepted ByWft;tIa Aren_� - Eniubyee ID#�10l''n'LlF�V0/f'•0{ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date _. Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount T Permit/ <br /> Coda Info B Cash Remitted Date Service Re uesl AtInv°Ice Well IDa <br /> All <br /> EHD U-OB 611 12019 J1Ett-cUMP PERM'. <br />