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MINIMUM UR tIONCEnE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE Owner - Operator (Hillside Or !l DATE ing) 04-21-2021 <br /> 1 4 <br />)14101.-‘7 <br />t CI f cote 7' <br />41,4) 2 2n 0 <br />,s+v <br />itit'4%,„,4Qk v (Q1 <br />SIGNED <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.sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />426 E Flora Street JOB ADDRESS CITY/ZIP Stockton, CA 95202 <br />N California Street 13-917-403 0.17 acres CROSS STREET APN PARCEL SIZE LAND USE APPLICATION # <br />Peter Sandlin C/o Degenkolb Engineers (for Owner) NomeitS Cealer FP61-ICTE 916-418-9100 OWNER NAME <br />OWNER ADDRESS 428 J Street, Suite 500 <br />CITY/STATE/ZIP Sacramento, CA 95814 <br /> <br />Hillside Drilling CONTRACTOR PHONE 209-815-5440 <br />CONTRACTOR ADDRESS P. 0. Box 143 <br />CITY/STATE/ZIP Tracy, CA 95378 <br /> <br />SUBCONTRACTOR/CONSULTANT Mid Pacific Engineering, Inc. (MPE) <br />PHONE 916-927-7000 <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive, Suite 20 CITY/STATE/ZIP West Sacramento, CA 95605 <br /> <br />LICENSE )( C-57 ii C-61 0 D-09 7 Other NUMBER 800276 EXPIRATION DATE C13°A1 I <br />BILLING PARTY: <br />= OWNER E CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:: General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392): Arsenic (4393) <br />INTENDED USE 0 Domestic/Private = Irrigation/Agricultural _J Industrial 7. Water Quality Monitoring ySoil Sampling/Characterization <br />fi Public Water System <br />If different from Owner Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK = New Well 7 Replacement Well = Well Alteration/Modification E Other :SS3NOCIV E Monitoring Well(s) # of wells X Soil Boring(s) 2 R ot borings = Geotechnical k of borings <br />n Out-Of-Service Well 7 Out-Of-Service Well Renewal 7 Cross-Connection Repair <br />ri New Pump fi Pump Replacement C Pump Repair 7 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method = Mud Rotary = Air Rotary i< Auger = Cable Tool = Push Point 7 Other <br />Proposed Well Depth 15 and 25 ft Excavation in diameter = Open Bottom = Gravel Pack/Gravel Size in diameter <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel fi. Plastic 7 Stainless Steel 7 Other <br />Grout Seal Depth 15 and 25 ft XNeat Cement (94 lb bag/5-10 gal water) E Sand Cement <br />= Bentonite (20% solids) 7 Other +- <br />Grout Placement Method = Pumped '''-Free Fall :] Other = Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller C Pump Contractor 7 Other <br />: Concrete Pedestal EDImensions: VVidth ft Length <br /> <br />ft Thick In F Christy Box C Stove Pipe <br />PUMP n Submersible: Turbine 7 Other HP Pump Set ft Standing Water Level ft <br />sack mix/7 gal water <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 />DEPARTMENT USE/ ONLY <br />Application Accepted By .- tZ Li---- Date 9k /Pi Area i .5bC "41 Employee ID# fielf; <br />Grout Inspection By Date ... SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />Soil Boring Inspection By /104tbe-O*4',k& Date 4/— 7 S —Z( Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />Cash_ <br />Amount <br />Remit .cl . <br />Permit) <br />Invoice # Well ID# <br />(43-7a i 0 <br />112/9._ <br />44,C) <br />at/ <br />I 24 <br />Iceofe)uest # wit <br />&V, /2+ 17 2-1-2L,0 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT