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VyELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL LEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 6701 Jack Tore Road I cirdzip Stockton, 95215 <br />CROSS STREET Mariposa Road APN 181-080-180-000 PARCEL SIZE 7.07 Acres LAND USE APPLICATION # <br />OWNER NAME ESCALON UNIFIE4 SCHOOL DISTRICT PHONE 209-838-3165 <br />li <br />OWNER ADDRESS 1520 Yosemite Ave4Je CrtY/STATEIZIP Esc,alon, CA, 95320 <br />CONTRACTOR MIDDLE EARTH Gb() TESTING INC P HONE (714) 633'5025 <br />CONTRACTOR ADDRESS 954 N LEMON STREET CITY/STATE/ZIP ORANGE, CA 92867 <br />SUBCONTRACTOR/CONSULTANT VValla-e-Kuhl & Associates 1PHONE 916'997-1546 <br />SUBCONTRACTOR/CONSULTANT ADDR 3050 Industrial Blvd CrtY/STATE/ZipWest Sacramento, CA 95691 <br />LICENSE VC-57 C C-61 0 D-09 0 Other NUMBER 899451 I <br />1EXPIRATION DATE 06/30/2021 <br />BILLING PARTY: E OWNER *ONTriACTOR i."'SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General <br />, <br />Mineral/Colifo Bacteria (4391) E Dibromochloropropane (4392) <br />I <br />0 Arsenic (4393) <br />INTENDED USE El Domestic/Private di Irrigation/Agricultural 0 Industrial H Water Quality Monitoring VSoil Sampling/Characterization <br />3 Public Water Systenh <br />If differeni from Owner WANK System Name Contact Name or Phone Number <br />TyPE OF WORK 0 New Well li R placement Well 0 Well Alteration/Modification 0 Other I <br />3 Monitoring Well(s) <br />1 <br />, # of wells 0 Soil Boring(s) # of borings VGeotechnical / I # or b.thigs <br />0 Out-Of-Service VVeli <br />0 New Pump 0 P mp Replacement <br />0 Out-Of-Service Well Renewal 0 Cross-Connection <br />0 Pump Repair 0 Raise Well (lasing <br />I Repair <br />WELL CONSTRUCTION <br />Drilling Method D Mud Rotary 0 AiN Rotary Auger 0 Cable Tool iti Push Point 0 Other <br />Proposed Well Depth 50 ft Excavation 2 in diameter C Open Bottom ° Gravel Pack/Gravel Size_ in diameter <br />0 Conductor Casing in diame+ / Conductor Casing Depth ft <br />Well Casing Diameter in T ckness/Gauge/ASTM Sched E Steel L Plastic LI Stainless Steel C Other <br />Grout Seal Depth f., [3 tl VNeat Cemeht (94 lb bag/5-10 gel water) 0 Sand Cement sack mix/7 water gal <br />C Other -1 [ . Bentonite (20% soils) <br />Grout Placement Method Li Pumped 0 Free Fall (Clther Flee fell vie 'Donis Pipe h Retardant / Acceleratori (name) <br />PEDESTAL Installed By Li Drillet C Pump Cont actor ::, Other <br />.0 Concrete Pedestal IDDImensfons: Width ft Length ft Thick 1 in .= Christy Box '2 Stove Pipe <br />PUMP .Li; Submersible° Turb he 0 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT <br />JOAQUIN COUNTY ORDINANCES, <br />CURRENT AND ACTIVE <br />WORKERS COMPEN TION <br />MINIMUM 4 <br />SIGNED <br />LAWS: Ill <br />(Al, <br />\ <br />I HAVE lilREPARED <br />STATE <br />WITH THE 1FALIFORNIA <br />THIS <br />LAWS, AND <br />CO <br />A , ki\NOTICE <br />APPLICATION AND <br />RULES AND REGULATIONS. <br />TRACTORS STATE <br />REQUIRED FOR <br />TITLE <br />THAT THE WORK <br />I <br />LICENSE BOARD <br />INSPECTIONS <br />r\ tin .r-‘ rrirt.0 <br />WILL DE <br />ALSO CERTIFY <br />AND THAT <br />- PLEASE <br />DONE IN ACCORDANCE WITH SAN <br />THAT MY REQUIRED LICENSE IS <br />I AM IN COMPLIANCE WITH ALL <br />CALL (209) 953-7697 1 <br />DATE <br />-. i. <br />il I, <br />ii <br />i <br />1 <br />i <br />.„(..) ---,.. ---, <br />i AA , _ . <br />F ile‘r4Y <br />,_ tto 41, II <br />111 J4 A, 4 <br />444, IY ‹.167 <br />i <br />i'l l /I? Q4mN <br />"t4V4fc • 01 . .. <br />www.sjciov.orIe SS31100V 311S I I I I I I I I I I L_L__1.11 1 _1 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date / ;13 07 / Area I/ Employee IlDtt A _s <br /> <br />Grout Inspection By Date SPECIAL Well Permit <br /> <br />Pump Inspection By Date <br /> <br />WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth _ _ <br /> ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />CCheeigie <br />Cash <br />Amount <br />Remitted Date Permit/ <br />ervice Request # Invoice # Well ID# <br />Li 37.7 I So CRIT-6--- 9-05-15 $9 5(= IIWI , lik)V6C,4 ( (P29- <br />END 43-06 6/11/2019 WELL /PUMP PERMIT