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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRES,2I I I N ZUCKERMAN RD AT GPS:37.996096-121.4777712(WELL#1) CITYIZIP STOCKTON,CA 95206 <br /> m <br /> b <br /> CROSS STREET N ZUCKERMAN RD APN C.r O PARCEL SIZE J��LAND USE APPLICATION# p <br /> m <br /> OWNER NAME AECOM PHONE <br /> OWNER ADDRESS 300 LAKESIDE DR CITY/STATE/ZIP OAKLAND,CA 94612 <br /> CONTRACTOR CORRPRO COMPANIES INC.. PHONE <br /> CONTRACTOR ADDRESS 2625C BARRINGTON CT CITY/STATE/ZIP HAYWARD,CA 94545 <br /> SUBCONTRACTORICONSULTANT CC., PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER A y 97$ EXPIRATION DATE <br /> BILLING PARTY: OWNER NONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial F- 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 New Well 7 Replacement Well E Well Alteration/Modification ;VOther <br /> MonitoringWell(s) #of wells i SoilBoring(s) #of borings - Geotechnical #or borings <br /> Out-Of-Service Well i- Out-Of-Service Well Renewal Cross-Connection Repair <br /> J New Pump Pump Replacement -Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger :-Cable Tool Push PointOther <br /> Proposed Well Depth 22 it Excavation 10 in diameter .Open Bottom Gravel Pack/Gravel Size in diameter <br /> ..Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesyGauge/ASTM Schad Steel =Plastic =Stainless Steel ❑Other <br /> Grout Seal D�th 100 ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> . <br /> Y Bentonite(20%solids) Other Bedfor�fe 100-54 a 4atcemest53-3 <br /> Grout Placement Method✓Pum ed ❑Free Fall C Other Retardant/Accelerator name <br /> Installed By Driller -Pump Contractor -I Other <br /> u Concrete Pedestal ,Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP 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 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 �L'" TITLE OPERATIONS MANAGER DATE_ 062020 <br /> MFNT <br /> 44 <br /> F��ED <br /> QvIN <br /> 0NMFNDUN rY <br /> EPgR rMFNr <br /> DEPARTMENT USE ONLY p //�� <br /> Application Accepted By Date Area 3 -/ Employee INP.A <br /> Grout Inspection By Date VbLb SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date c�Constructed Well Depth tt <br /> COMMENTS <br /> %S:., <br /> i���A <br /> PE SC Received Check#] Amount Date Permit/ Invoice a Well IN <br /> Codes InfoCash Remitted Seryice Re uest# <br /> 3-� <br /> EHD 43-06 6M]12019 �/ �. �V L 3 /I WELL/PUMP PERMIT <br />