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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 800 Woodbridge Rd E CITy/Zlp Woodbridge/95258 <br /> In <br /> CROSS STREET Fairway Ct 013-120-56 D <br /> APN PARCEL SIZE 36.43 Acres LAND USE APPLICATION# o <br /> a <br /> �r p m <br /> l.. <br /> OWNER NAME Gam^- FnAr^ +y�..Q^^ A // / 3 (� yl / u PHONE (831)515-8332 y <br /> OWNER ADDRESS �� - • V F� CITY/STATE/ZIP <br /> CONTRACTOR West Coast Exploration Inc PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITYISTATE2IP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL Inc PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 kiernan Ave STE 150 CITYISTATE/ZIP Modesto/CA/95356 <br /> LICENSE &C-57 ❑C-61 ❑D-09 ❑Other NUMBER 870761 ExPIRATION DATE 1/31/2022 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR S SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring D Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferent from Omer Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Afteration/Modification C Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) •of bodngs 5it Geotechnical 2 s 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 9 Auger ❑Cable Tool ❑Push Point = Other <br /> Proposed Well Depth 20 ft Excavation 4 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 )(3 ft H Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack m1x/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped []Free Fall ik Other Tremie a in ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP []Submersible[]Turbine ❑Other HP Pump Set ft 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 lea4l LSP.!' ' X� llI TITLE Staff Geologist DATE 10/15/20 <br /> S E JE I JAIT IT A IC 1H JE ID <br /> ?per <br /> DEPARTMENT <br /> � iNC <br /> OV <br /> DEPARTMENT U4SE NLY <br /> Application Accepted By� Date /5� v4R2 Area Employee ID# NT <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date � ,-� G WAIVER Received <br /> Soil Boring Inspection By Date 0 2 J7w Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date PermiU Invoice# WeIIID# <br /> Codes Info B Cash Remitted Service Request 9 <br /> 3 7, CAM 0SU <br /> EHD 4306 61172079 I I /�� �� WELL/PUMP PERMIT <br />