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SUBCONTRACTOR/CONSULTANT BSK Associates PHONE 916-853-9293 <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3140 Gold Camp Dr. #160 crryisTATErzip Rancho Cordova, CA 95670 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STocicroN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT Www.s • ov.or. /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2482 Carpenter Road <br /> <br />cftyrzip Stockton, CA 95205 <br /> <br />CROSS STREET Pock Lane APN 17914018 PARCEL SIZE a1 ,7e LAND USE APPLICATION /I <br />OWNER NAME Estrella L Jose Family PHONE 209-948-2369 <br />OWNER ADDRESS 2482 Carpenter Road crryisTATEizie Stockton, CA 95205 <br />CONTRACTOR Baja Exploration PHONE 760-743-7678 <br />CONTRACTOR ADDRESS 1915 Commercial Street CrrY/STATE/Z0. Escondido, CA 92029 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 804318 EXPIRATION DATE 02/28/2022 <br />BILLING PARTY: <br />OWNER <br /> <br />CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAPAPUNG: 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 <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br /> <br />Soil Boring(s) # of borings X Geotechnical Q S ot borings <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />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 4-30 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 4-30 ft x Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method 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 ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 />SIGNED A....44,-).44 TITLE Owner DATE 1/14/2021 <br />IIMUN,48,7 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />11 <br />DEPARTMENT USE QNLY <br /> <br />Application Accepted By Date a•C / <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection B _ 1b2.4. IMV_02.1% Date J \ <br />Area ifrq Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check/I/ <br />a Cagt <br />Amount <br />Remitted Date Permit/ <br />Rpcpie?t # _Smeikf Invoice 1r Well ID# <br />113797 is-D <br />/3/ <br />AMCX 415-010 1 21014 <br />1 1 <br />14. i rutivit, <br />1 /,l /21 <br />_ . <br />EHD 43-06 6/11/2019 vi I I 72 0, 0 G <br /> <br />WELL /PUMP PERMIT