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t <br /> WELLIPUMP 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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> Joe ADDRESS 3009 Pock Lane CITY/ZIP Stockton/95205 m <br /> D <br /> CROSS STREET E Loomis Rd APN 179-120-11 PARCEL SIZE 23 Acres LAND USE APPLICATION# a <br /> M <br /> OWNER NAME Anthony Barkett PHONE �! <br /> OWNER ADDRESS 119 East Weber Ave CITY/STATE/ZIP Stockton/CA/95202 <br /> CONTRACTOR West Coast Exploration Inc PHONE 209-985-7541 <br /> CONTRACTOR ADDRESS P.O.Box 133 CIN/STATEIZIP Escalon/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CALInc PHONE 209-543-1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 CITY/STATE/ZIP Modesto/CA/95356 <br /> LICENSE N C-57 C-61 ❑D-09 ❑Other NUMBER 870761 ExPIRATION DATE 1/31/2022 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR 12 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 2 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 /> MonitoringWell(s) #of wells ❑Soil Boring(s) tofborings NGeotechnical 9 0ofbonngs <br /> C Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump G Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION -"661 5tely) <br /> Drilling Method El Mud Rotary ❑Air Rotary 0 Auger ❑Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 10 to 30 ft Excavation 4 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 YO —40 ft iR Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall R Other Tremie d In ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions.Width ft Length ft Thick in D Christy Box `J Stove Pipe <br /> PUMP ❑Submersible[]Turbine ❑Other HP Pump Set It 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 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 Geologist DATE 1/6/2021 <br /> * SEE I JAITTACHED <br /> 6 20 <br /> EI '01) <br /> rt <br /> qC <br /> Rrife <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ Date )4,,�'x f�� Area Employee ID# l <br /> Grout Inspection By Date ❑ 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 CheckX/ Amount Permit/ Invoice# Well ID# <br /> Codes Info Date Cash Remitted Service Re uest# <br /> LIKE: 17 3,--- <br /> Ei04306 6/112919 _- -r —* /� ���V V WELL/PUMP PERMIT <br />