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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENV#a01 mwffAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6)232(209)4118.4420 <br /> NON-REFUNDABLE PERMIr wwwsjgov.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _.'77 57 R, 99, cn mr Stockton,9521377260 10 > <br /> m <br /> CROSS STREET Qantas Lane AP&117726 0 14X <br /> and PARCEL SIZE aOl"USE APPLJCATION# o <br /> OWNER NAME �L�✓1 —70AQ UIM �/,y1(.]„yJ/J'� y PHONE 510-267r�-A3�4p2�0 <br /> OWNER ADDRESS 3�LL G V� 1`! CI,,,,ATE,L Oakr�Jd. CA-TlV V I S <br /> CONTRACTOR West Coast Exploration PHONE 209-985-7541 <br /> CONTRACTOR ADDRESS PO Box 113 cm/srATE2m ESCalon,CA 95320 <br /> SUBCONTRACTOR/CONSULTANT ENGEO Incorporated-Jason Sedore PNoNE 925-7t9-0822 _ <br /> SUBCONTRACTORICONSULTANT ADDRESS 17278 Golden Valley Pkwy. CITYISTATErzp Lathrop CA 95330 <br /> LICENSE xC-57 C-61 D49 Other NUMBER 870761 EIIRATIONDATE 1/31/2022 <br /> BILJJNG PARTY: -:OWNER CONTRACTOR C'SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:-General MineraUColiform Bacteria(4391)_Dibromochloropropane(4392)1 Arsenic(4393) <br /> INTENDED USE DomesticJPrivate IrrigatiorJAgricultural - Industrial Water Quality Monbring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Waler System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -Replacement Well _ Wel Alteration/Modification L Other R A y <br /> Monitoring Weil(s) #of wells :Soil Boring(s) RdtimirV. X Geotechnical 9 x of borings <br /> Out-Of-Service Wel _OW-OEService Well Renewal ^Cross-Connedion Repair ^ <br /> New Pump Pump Replacement i'Pump Repair RarseWellCasing <br /> `O WELL CONSTRUCTION OC <br /> Drilling Method Mud Rotary Air Rotary �Auger -Cable Tool . Push Point X Other 5 11 .1 h `T 5 <br /> Proposed Well Depth 25 It Enervation 4 in diameter Open Bottom ..Gravel PaddGravel Sae in diame `O <br /> Conductor Casing in diameter / Conductor Casing Depth ft ; If - �pOA('/�N C �O <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad -Steel __Plastic : Stainless Steel - Other P. <br /> cyst�N q�NT <br /> Grout Seal Depth 25 ft X Neat Cement M Ib hal;'-10 gat water) Sand Cement sack rrdJd'7 gat water FP '7 TWIT,, Y <br /> .Bentonite(20%solids) -Other <br /> Grout Placement Method 'Pumped Free Fall Other Retardant/Accelerator(name) <br /> EDFSTAL Installed By Dribs -Pump Contractor Other <br /> Concrete Pedestal Dimerislons:Width ft Length ft Thick in Christy Box _Stove Pipe <br /> PUMP Submersibles Turbine Other HP Pump Set it Standing Water Level it <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFqRN1A CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA WS. <br /> MINI 48 URA AN E NOTICE REQUIRED FOR PECTIO S-PLEASE CALL(209)953-769 <br /> SIGNED TITLE �',I ��' DATE C5 <br /> See attached site plan <br /> DEPARTMENT USE NLY �) <br /> Application Accepted By � i� Date �y Upry Area I '7L Employee ID# ✓ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By „Jnr_1�� r o'. War'L Date L ^- ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received Check#/ Amount Date Permit/ �tpky� Wellllbf <br /> Codas Info .-Cash Remitted Service Request:0 <br /> 4172o l .Is'W W49004 <br /> EHD X306 flr11?.019 WELL[PUMP PERMIT <br />