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I <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 /> to <br /> Jos ADDRESS 9820 Ronald E McNair Way(Misasi Park) cITYmP Stockton, CA 95210 (DD7 <br /> CROSS STREET West Lane APN 08405023 PARCEL SD:E10.74 ac LAND USE APPLICATION# A <br /> m <br /> OWNER NAME City of Stockton PHONE 209-830-3200 N <br /> OWNER ADDRESS 425 N EI Dorado Street CITY/STATE/ZIP Stockton,CA 95202 <br /> CONTRACTOR Baja Exploration PHONE 760-743-7678 <br /> CONTRACTOR ADDRESS 1915 Commercial Street CITY/STATE/21P Escondido, CA 92029 <br /> SUBCONTRACTORICONSULTANT BSK Associates PHONE 916-853-9293 <br /> SUBCONTRACTOR/CONSULTANTADDRESS314O Gold Camp Dr.#160 CITY/STATEIZIP Rancho Cordova, CA 95670 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 804,118 EXPIRATION DATE 02/28/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X 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 X 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings x Geotechnical 3 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 X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10-35 ft Excavation 6-8 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 10-35 ft x Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped x Free Fall Other 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 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �,,J% r,l� TITLE Owner DATE 10/16/2020 <br /> 77-1-1 <br /> F yMFN <br /> N <br /> V/ <br /> E qR�q�NTY <br /> MF/yT <br /> f / DEPARTMENT USE ONLY <br /> Application Accepted By — 1��✓ Date D P b v Area 497 5 hWj Employee ID# DA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By r°'N-rf 4s t ^ti Date EO 27 Z Z0 Constructed W I De th ft P red f j <br /> �OMMENS �► 11} I N h . V, <br /> �r 1 <br /> P�otitbth6l` n n Svc h0 Nae Yrs�O {R6ii 1�► dPp <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Se ry c e ues # <br /> 3712 Id Ste- o <br /> 01 <br /> EHD 43-06 6111/2019 (A4.' <br /> A ' WELL/PUMPPERMIT <br />