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r �T <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 545 E Cleveland Street G CITY/ZIP Stockton,95207 m <br /> D <br /> CROSS STREET N California Street APN 12723005 PARCEL SIZE 0.54 aU-AND USE APPLICATION# °op <br /> OWNER NAME Ducem LLC PHONE 209-224-7412 w <br /> OWNER ADDRESS 7497 Kile Road CITYISTATEIZIP Lodi,California 95242 <br /> Ul <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 tTj <br /> n <br /> CONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/LP Fresno California 93722 <br /> SUBCONTRACTOR/CONSULTANT Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> .7 <br /> a <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/ZIP Fresno,California 93722 <br /> ti <br /> LICENSE f C-57 C-61 D-09 Other NUMBER 970772 EXPIRATION DATE 3/31/2022 <br /> BILLING PARTY: 'OWNER .CONTRACTOR '✓SUBCONTRACTOR/CONSULTANT <br /> O <br /> DOMESTIC WELL SAMPLING:i i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)!1 Arsenic(4393) <br /> INTENDED USE Domestic/Private !1 Irrigation/Agricultural i Industrial Water Quality Monitoring ✓Soil Sampling/Characterization 0 <br /> Public Water System n <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells ✓Soil Bonng(s) 3 #of borings Geotechnical #of borings p <br /> w <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary i Air Rotary ✓Auger i Cable Tool Push Point i Other <br /> Proposed Well Depth n/a ft Excavation in diameter Open Bottom i Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched i Steel i i Plastic i Stainless Steel i Other <br /> Grout Seal Depth 5 to 25 ft ✓Neat Cement(94 lb bag/5-10 gal water) i i Sand Cement sack mix17 gal water <br /> i Bentonite(20%solids) Other <br /> Grout Placement Method Pumped ✓Free Fall ✓Other Tremmle Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width ft Length ft Thick in Christy Box i Stove Pipe <br /> PUMP i Submersible. Turbine 1 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 AC VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSC'O�^MPE SATION LAWS. <br /> MIhk1M 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Geotechnical Staff Engineer DATE 10/20/2020 <br /> YMFNT <br /> C'ei v p <br /> T 3 0 2020 <br /> i �NMENTgN TY <br /> )EPA T4jEtVT <br /> DEPARTMENT USE DNLY (- <br /> Application Accepted ByDate "✓, r Area R 5^'�K�N Employee ID# _ <br /> Grout Inspection By Date I I SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permit] Invoice# Well ID# <br /> Codes Info B Remitted Ispalice a uest# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMrr <br />