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1.0641 <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 ADDRESS760 Industrial Dr CITY/Zlp Stockton 95206 A <br /> M <br /> CROSS STREET S Airport Way APN 177-28-024 PARCEL SIZE 10.53 LAND USE APPLICATION# O <br /> m <br /> OWNER NAME Campbell S/orupr-��Yj�l1� )�yyli •I HSV LLC /� PHONE 908,-20/5-3484 N <br /> OWNER ADDRESS ( ^, T��.,( P'lCITY/STATEIZIP Ce.,writ,r7 <br /> CONTRAC OR D�E� J?912 L PHONE <br /> CONTRACTOR ADDRESS1V J!/(�6"1(„1r7Y�lCtr/L 116 CITYISTATEIZIP Lod1 ��pjyU <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 X C-61 C D-09 Other NUMBER 1055434 ExPIRATION DATE 7:31;2021 <br /> BILLING PARTY_ ,OWNER -CONTRACTOR F SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE I Domestic.+•Private Imigation AgricultLiraI A Industrial - Water Quality Monitoring L Soil Sampling/Characterization <br /> Public Water System <br /> `drt'eren,from Domer 4-iter System Name Contact Name or Phone'lumber <br /> TYPE OF WORK I New Well I Replacement Well I Well Atte ratio mModification Other <br /> _ Monitoring Well(s) #of wells t_ Soil Boring(s) A-f k-nq' J Geotechnical <br /> c���N <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair T <br /> CD <br /> New Pum Pum Replacement )K Pum Repair _ Raise Well Casio k <br /> WELL CONSTRUCTION 20 <br /> Drilling Method I Mud Rotary -1 Air Rotary Auger I Cable Tool Push Point Other SA 20 <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom r Gravel PackiGrav"AE ,V,nIR � ./N- Comei�r <br /> Conductor Casing in diameter Conductor Casing Depth It I r1 IDEPqN7-,4 L <br /> Well Casing Diameter in Thickness;'Gauge;ASTM Sched _ Steel _ Plastic _ Stainless Steel _ Other <br /> Grout Seal Depth ft i Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack mrx.7 gal rtater <br /> Bentonite(200%solids) L Other <br /> Grout P lace rnen t Method L Pumped 1 Free Fall I Other I Retardant:Accelerator(name) <br /> PEDESTAL Installed By -1 Driller F Pump Contractor -1 Other <br /> Concrete Pedestal _Dimensions:VMdth ft Length It Thick in _ Christy Box -i Stove Pipe <br /> PUMP Submersibles Turbine f Other HP 700 Pump Set 720 ft Standing Water Level 32 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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 8 JR A jVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)963-7697 <br /> SIGNED_,__ TITLE CEO DATE 10/14(2020 <br /> c 1 WELL/PUMP IS LOCATED NEXT TO <br /> THE CAMPBELL SOUP TANK. <br /> 0, y�. p <br /> —- , -p` , <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By Date A3) ao d 0 Area 5 �7Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> PL Mp Inspection By }!µnL S f,4v Lcd' c. i�y'i Date 12� y'v WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth — ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B Remitted Service Request# <br /> filo A?-OE h�11 r'f.1� WELL!PUMP P[RMrr <br />