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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 3651 Arch Rd CITY/ZIP Stockton/95215 <br /> in <br /> CROSS STREET 99 E Frontage APN 179-48-007 PARCEL SIZE 1.79Aues LAND USE APPLICATION# o <br /> a <br /> OWNER NAME Jlvtesh S.GIII PHONE w <br /> OWNER ADDRESS P.O.Box 235927 CITY/STATE21P Encinatas/CA/95023 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CITY/STATE21P Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL Inc PHONE (209)543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 CITY/STATE/ZIP Modesto/CA/95356 <br /> LICENSE N C-57 ❑C-61 ❑D-09 ❑Other NUMBER 870761 ExPIRATION DATE 1/31/2022 <br /> BILLING PARTY: Ll OWNER ❑CONTRACTOR N SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Li DomesticlPrivate U Irrigation/Agricultural ❑Industrial U Water Quality Monitoring it Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK a New Well rl Replacement Well U Well Alteration/Modification ❑Other <br /> riMonitoringWell(s) #ofwells ❑Soil Boring(s) •ofborings R Geotechnical 5 0ofbohngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method U Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 40 ft Excavation 4 inches 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 -.10 gi Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonge(20%solids) U Other <br /> Grout Placement Method ❑Pumped ❑Free Fall W Other Tremie it in ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By CI Driller a Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑DimensionsWidth It Length It Thick in ❑Christy Box U Stove Pipe <br /> PUMP LI Submersible Ll Turbine Ll 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 TITLE Staff Geologist DATE 10/30/2020 <br /> S E E A T T A C H E D <br /> F FNT <br /> � VFD <br /> 0 ?020 <br /> U CO <br /> P FN7k <br /> y�►�J/ DEPARTMENT USE ONLY TMFNT <br /> Application Accepted By /�"�� Date 3J �,�< Area I $t"k4`f Employee ID#_ .�/L <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date IW2Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WeIIID# <br /> Codes Info B Cash Remitted Service Re ,est# <br /> EHD4106 Stil2019 t 1 WELLIPUMPPERMIT <br />