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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE. STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1,1 i CI 0 E0L5t I-lanr) Inc K Lane_ cirdzip 5 -ioct it,n el 57.-I 1 <br />CROSS STREET /41‘krallitkilnA. D r. APN i 30— 0 3 - 00 C. PARCEL SIZE .'1 3 LAND USE APPLICATION # <br />OWNER NAME <br />13 <br />PHONE 5 <br />OWNER ADDRESS 3 63 ) W . iriel re 1 1 Lei 5ie II,2 CrreISTATE/Zip :5:tte: kfcira 9 5-Rig <br />Neil 0 Anderson and Associates CONTRACTOR PHONE (209) 588-2219 <br /> <br />CONTRACTOR ADDRESS 902 Industrial Way CRY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT Same as above <br />Same as above SUBCONTRACTOR/CONSULTANT ADDRESS crryismnizip Same as above <br />Lodi, CA 95240 <br />PHONE Same as above <br />LICENSE XC-57 C-61 I D-09 I Other NUMBER #669004 EXPIRATION DATE 05/31 /2021 <br />BILLING PARTY: L OWNER X CONTRACTOR i SUBCONTRACTOR/CONSULTANT <br />,A=111111111=111MMIMIll MMEMEMMEMEMMINIMM MMEMMEMMEMEMOMME —.REMMEMEMMEMMEMEM MMEMMEMMIIMMEMINIM MEMEMEMMEMMIONIMM MMMINIMMEMMEMMEMM <br />, MEMEMMIIMEW7NMEMM IIMMEMMEMMEMMEMME <br />1 MIIIMMEMMEMM6LOTME MMEMMEMML1SNULHO/1 MEMMEMMEMMILZWANU MMEMMEMOMMUMMI&el MIIMMEMMEMOMMOMM mommomammirmmm MEMMEMMAREWMMOMM - OMMEMMYAMWTOCUMME ...MMEMMINIMMUMWENQM <br />ft Thick <br />PEDESTAL <br />in Li Christy Box u Stove Pipe <br />Installed By L_ Driller Pump Contractor Other <br />Concrete Pedestal uDimensions: Width ft Length <br />Pump Set ft Standing Water Level HP ft PUMP I Submersible: Turbine Other <br />SIGNED_XIS Staff Engineer TITLE DATE 3/8/2021 <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 />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool - Push Point - Other <br />Proposed Well Depth c> ft Excavation g in diameter L Open Bottom Gravel Pack/Gravel Size in diameter <br /> <br />I. Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel I Plastic I Stainless Steel I Other <br /> <br />Grout Seal Depth 217 tt )‹ Neat Cement (94 lb bag/5-10 gal water) L Sand Cement <br />11 Bentonite (20% solids) 1 Other <br />Grout Placement Method L. Pumped X Free Fall 0 Other 01 Retardant / Accelerator (name) <br />sack mix/7 gal water <br />J 9. laporl,. efl <br />M <br /> <br />WELL/PUMP PERMIT <br />DOMESTIC WEU. SAMPLING: iiGeneral Mineral/Coliform Bacteria (4391)11 Dibromochloropropane (4392) u Arsenic (4393) <br />INTENDED USE Domestic/Private I Irrigation/Agricultural Industrial Water Quality Monitoring 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 E Replacement Well <br />Monitoring Well(s) # of wells <br />5 Out-Of-Service Well <br />H New Pump Pump Replacement <br />0 Well Alteration/Modification El Other <br /> <br />r Soil Boring(s) # of borings Geotechnical Sl ot borings <br />E Out-Of-Service Well Renewal Li Cross-Connection Repair <br />Pump Repair n Raise Well Casing <br />47. <br />Area t 2 /q 6 Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENgti <br />Employee ID# <br />E SPECIAL Well Permit <br />0 WAIVER Received <br /> <br />Date 4/2- q/7171" / Constructed Well Depth d W . 0 OW Nit oo 9 6 6 <br />D,cPARTMENT LI,SE, ONLY <br /> Date 3/q/11 <br />Date <br />Date <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />._.._cre_s_kitt..." Amount <br />Remitted MI Permit/ <br />Service Request # Invoice # Well ID# <br />- ash <br />(43701 150 <br />0.7,0 <br />7Z0 u21-15 -1.4.3 .3c9111100041774 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT