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303 N El Dorado Street <br /> APN 13clo8003 <br />A Te_ 60;i065 CO <br />Lop Mohtomery <br />Moore Twining and Associates Inc <br />CONTRACTOR ADDRESS 2527 Fresno Street <br />crrazip Stockton <br />PARCEL SIZE q LAND USE APPLICATION # <br />PHONE <br />CrrY/STATE/ZiP 61Y1ILfYI c isC1) <br />PHONE 559-268-7021 <br />CITY/STATE/ZIP <br /> Fresno, CA 93721 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />E Miner Avenue <br />OWNER ADDRESS <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT TGR Geotechnical, Inc PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS 3037 S Harbor crry/sTATErzip Santa Ana, CA, 92704 <br /> <br />LICENSE XC-57 C-61 D-09 Other NUMBER 506159 EXPIRATION Dm-L-02-28-2023 <br /> <br />BILLING PARTY: OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />MINIMUM 48 OU CE QT10E REQ <br />SIGNED <br />ED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE Division Manager, PG DATE 01-05-2021 <br />41 444, <br />A/s4 <br />C. <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 />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />II different from Owner Water System Name Contact Name or Phone Number <br />Well Alteration/Modification Other <br />Soil Boring(s) # of borings XX GeOteChnical 4 <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary . Air Rot ry Auger 11 Cable Tool Push Point X Other Hollow Stem Auger <br />Proposed Well Depth 1x25, 4x13Excavation 6 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. ...Qther <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) XSand Cement 'WI DaCktIll sack mix/7 gal water <br />Bentonite (20% solids) Other Me? 544k hid <br />Grout Placement Method Pumped XX,Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: VVidth ft Length <br /> <br />fl Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level <br />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 />TYPE OF WORK New Well <br />Monitoring Well(s) <br />Replacement Well <br /># of wells h ot boring, <br />Out-Of-Service Well <br />WELL CONSTRUCTION :SS3HCICIV 3i1s DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />COMMENTS Iiirj 11 yln-4- • q 0I-jig-3 <br />Soil Boring Inspection By P,IIPPTII557 • <br />Date Pump Inspection By <br /> <br />.1"...., Date <br />1 Area istigkiori Employee ID# DA <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />info <br />Received Checktll Amount <br />Remitted Dar 4 <br />'6 <br />16 ,2,1 Permit/ va Invoice # Well ID# <br />qva is-0 ael- Vi-- Ilica <br />c tTna., <br />,. II <br />0-1617 WELL /PUMP PERMIT EHD 43-06 6Th/2019