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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS 3263 E.Cherokee Road Cm/LP Stockton / 9520i n <br /> (Acres) ° <br /> CROSS STREET Newton Road APN 132-070-100-000 PARCEL SIZE 139.800 LAND USE APPLICATION# A <br /> A <br /> OWNER NAME Randall I'l-tal Raj kovich-Contact:Jery Grunzinger,KP Development -DNS 3/4.960.0843 <br /> OWNER ADDRESS 8025.Forsvth BOulc%ard 1ITYISTATE/2.IP St.LoDls,MO 63105 <br /> CONTRACTOR West Coast Exploration-Andrew Hernandez.Owner/Operator PHONE 209.98i,7541 <br /> CONTRACTOR ADDRESS 11.0.Box 133 CITY/sTATE/zIP Escalon,CA 9i320 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01/31/2020 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> 11 different I—Owner Water System Name on a ame or riff NuiF&i <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) N of borings X Geotechnical 8 0 of borings <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 5 to 20 it Excavation 4 1/2 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(ujjdepth ft X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mlx/7 gal water <br /> Bentonile(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal DimensionsWidth ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible 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 COMPENN LAWS <br /> SATI . <br /> MINIM OU i ANCE NO E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE OTcner/Operator DATE 03/14/18 <br /> 1@F11 C M�^►T <br /> EI� D <br /> AR ' y 2018 <br /> VIRONM C01JN7Y <br /> T H D,p E MENl <br /> r <br /> IPAR MENT U E O Y <br /> Application Accepted ByDate {9 Area Employee I <br /> Grout Inspection By Dale L Well Permit <br /> Pump Inspection By V Date V WAIVER Received <br /> Soil Boring Inspection ByDate Constructed Well Depth ft <br /> COMMENTSW reLlY_eLLl " <br /> PE SC Received Check Amount Date PermiU Invoice# Well ID# <br /> Codes Info B emitted Service Request# <br /> Jfr D <br /> EH O 43.0 3 <br /> 4130111 WELL IPVMP PERMIT <br />