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r <br /> 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 4124 Cherokee Road cl-rygjp Stockton,95215 <br /> D <br /> CROSS STREET Wilcox Road APN 087-100-72 PARCEL SIZE 20 aC. LAND USE APPLICATION# <br /> m <br /> OWNER NAME Jim Nylen PHONE 209-951-5787 y <br /> OWNER ADDRESS 3439 Brookside Drive,Suite 104 CITYISTATEZP Stockton,CA 95219 <br /> .A <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITYISTATE/zIP Fresno,California 93722 <br /> SUBCONTRACTOR/CONSULTANT Salem EngineeringGrOUp.Inc. PHONE 559-271-9700 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4729 West Jacquelyn Avenue CITYISTATE/zIP Fresno,California 93722 <br /> N <br /> LICENSE /C-57 C-61 D-09 Other NUMBER 970772 ExPIRATION DATE 3/31/2022 <br /> :n <br /> BILLING PARTY: OWNER CONTRACTOR 'J SUBCONTRACTOR/CONSULTANT n <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) p <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring J Soil Sampling/Characterizabon <br /> n <br /> Public Water System p1 <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other M A I-r <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings /Geotechnical eight of borings C jE/V v <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair C►D <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION 012020 <br /> Drilling Method Mud Rotary Air Rotary J Auger Cable Tool Push Point Other <br /> Proposed Well Depthft Excavation in diameter Open Bottom Gravel Pack/Gravel Size lultv <br /> Conductor Lasing in diameter / Conductor Casing Depth ft HEALT/R NMENT UNTY <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic ' Stainless Steel Other H P 7 L <br /> Grout Seal Depth 5 to 40 ft J Neat Cement(94/b bag/5-10 gal water) i Sand Cement sack mix/7 gal water ENT <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped ✓Free Fall ✓Other Tren2f131e Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller 'Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 1 Other HP Pump Set ft Standing Water Level It <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 /> MIN(t{A M 4 OUR AD NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED '� TITLE Geotechnical Staff Engineer DATE 9/24/2020 <br /> DEPARTMENT USE I NLY (� /� <br /> Application Accepted By <— Da—Da... �D�o Area � ! Employee ID# F)Q <br /> Grout Inspection By Dale V SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Re uest# <br /> 1137 50 120fJ I <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />