Laserfiche WebLink
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 1998 Yosemite Ave CITY/LP Escalon,CA 95320 m <br /> Sierra Drive 8 ac. s <br /> CROSS STREET / t APN! 22720024 PARCEL SIZE LAND USE APPLICATION# z <br /> OWNER NAME [_$C c,�CY-� („/A 1(1rGl sc.ho-i DI S 1/ .�t PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP- <br /> CONTRACTOR Neil O'Anderson and Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATE/ZIP Lodi,CA 95240 <br /> SUBCONTRACTOR/CONSULTANT H1 Drilling Company,LLC PHONE(916)213-7231 <br /> SUBCONTRACTORICONSULTANT ADDRESS 1400 Kitchner Rd CITY/STATEIZIP Sacramento CA 95822 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER #10006095 EXPIRATION DATE 08/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural i Industrial 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 I 1 Replacement Well i Well Alteration/Modification i Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings 1{Geotechnical_2 —#of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary )�Auger I Cable Tool Push Point Other <br /> Proposed Well Depth 15 ft ft Excavation 4e in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1:5� ft X Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mbd7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped X Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> Concrete Pedestal :Dimensions:Width ft Length ft Thick in Christy Box _ Stovepipe <br /> PUMP SubmersibleTurbine 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--.-y .y__ - TITLE Staff Engineer DATE 11/23/2020 <br /> . - a <br /> Rpg r�1 <br /> FCFj�NT <br /> ' q ?0?0 <br /> ... . : R-UZA,c <br /> A� pEpMFiyo, H1y <br /> m STM NT <br /> + y 40 <br /> I— — <br /> �J //, DEPARTMENT USE ONLY I <br /> Application Accepted By p fU L' Dale II C� �OaU Area 5<11 fw (f1 Employee ID# ' " <br /> Grout Inspection By 11. Date�� SPECIAL Well Permit <br /> Pump Inspection By T Date WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft L <br /> COMMENTS (- C a bJA 15 b'1 2/2C / /L9 ( 2 F ar 7JL/7 IG LF NQYL7 <br /> I ii <br /> PE SC Received r ChecW Amount Date Permit/ Invoice# Well ID# n <br /> S. <br /> Codes Info B Remitted rvice Request# <br /> �a ISO 20 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />