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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 11253 Thornton Road CITv/ZIP Stockton,CA 95209 m <br /> Eight Mile Road 05520003 4.60 ac v <br /> CROSS STREET 9 APN D LPAR-}CEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME PhrC1bUC/M/h;I'xmS`!�'!rlV14e-Q Wddh'S er„Pl a PHONE(209)244-8463 <br /> OWNER ADDRESS p.O UJA 6906)0 CrfY/STATERIP S I DJ+ Oillq Q15d b q <br /> CONTRACTOR Neil O'Anderson and Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITYISTATE/ZIP Lodi,CA 95240 <br /> SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above <br /> SUBCONTRACTORICONSULTANT ADDRESS Same as above CITYISTATE/ZIP Same as above <br /> LICENSE XC-57 - C-61 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2021 <br /> BILLING PARTY: -OWNER XCONTRACTOR 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 3 Replacement Well Well Alteration/Modification n Other <br /> Monitoring Well(s) #of wells Soil Borings) #of borings �'Geotechnical 2 #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 7 Air Rotary )(Auger ❑Cable Tool Push Point I] Other <br /> Proposed Well Depth 15,20 It Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad -1 Steel Plastic Stainless Steel G Other <br /> Grout Seal Depth 5 to 20 It )<Neat Cement(94 lb bagIS-10 gal water) Sand Cement sack mixfl gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method - Pumped Y Free Fall Other Retardant i Accelerator name <br /> 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_ TITLE Staff Engineer DATE 8/21/2020 <br /> TT El <br /> YMENT , <br /> CEIVED <br /> 2 5 2020 <br /> QUIN COUNTY <br /> ONMENTAL <br /> , a <br /> EPARTMENT <br /> t <br /> DEPARTMENT <br /> USE ONLY <br /> Application Accepted By Date Date O �.5 �(lo�b Area II Employee ID# D14 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Bor ngLect on By Date q 71 Con tructed Well Depth It <br /> COMMENTS ntnr �/ VV 'V"I P.! fb 'be U La t,.,)1efp li 1S .ID esS A_ 01 �11� <br /> bu re wlp IF <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Se ice Re uest# Invoice# Well ID# <br /> LT :3 od <br /> EHD 43-06 611112019 �� /)�!/�O��� ,/ WELL(PUMP PERMIT <br />