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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205 -6232 (209) 468-3420 NON-REFUNDABLE PERMIT /SO WWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4,1.1SLEast Hammer Lane crryizip Stockton, CA 95212 CROSS STREET Moreland Street ApN 13003006 —' - 7 PARCEL SIZE.' .43 ac. LAND USE APPLICATION # OWNER NAME qi90 4I ft)- Lzine 1-1-6 PHONE e. . i c; e S. .1..e / I 3 crry isTATEizip .2 f:f. js3 --f 6 ;1 1 (.c- -71 ci OWNER ADDRESS 3 i3 3 / Pi 6:, r G [1 L.m CONTRACTOR Neil 0' Anderson and Associates PHONE (209) 588-2219 902 Industrial Way CITY/STATE/ZIP Lodi, CA 95240 CONTRACTOR ADDRESS SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above SUBCONTRACTOR/CONSULTANT ADDRESS Same as above CITY/STATE/ZIP Same as above LICENSE I C-57 [ C-el _I D-09 I Other NUMBER #669004 EXPIRATION DATE 05/31/2021 BILLING PARTY: I OWNER )(CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAPAPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK I New Well r Replacement Well Well Alteration/Modification Other Monitoring Well(s) # of wells Soil Boring(s) *of b""gs K Geotechnical /.3. #01 borings . Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair New Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Method 1 Mud Rotary Air Rotary 14 Auger I Cable Tool Push Point . Other Proposed Well Depth 20 ft Excavation 6 1/4 in. in diameter , Open Bottom i Gravel Pack/Gravel Size in diamet, .. Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel Plastic Stainless Steel Other Grout Seal Depth 20 ft )( Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal 4 • Bentonite (20% solids) Other 42414, I Grout Placement Method Pumped X Free Fall li Other Retardant / Accelerator (name) 41Q1 4 i 41,7 PEDESTAL Installed By 1 1 Driller I Pump Contractor [ Other eke ot I Concrete Pedestal I I Dimensions: Width ft Length ft Thick i I Christy Box 1 ; Stove Pi PUMP I Submersible 1 Turbine I Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED_Xid TITLE Staff Engineer DATE 6/1 6:14. ed ons DEPARTMENT USE ONLY Application Accepted By 2--Z/1--- Date L1/12,/I?/ Area di q Employee ID# Grout Inspection By Date 7 SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By ...0k•or...6;. Date, 1.11 Constructed Well Depth COMMENTS ..Tf 5 -IC i 4. pro:N.)/ etif i vpmiiii ,p pipe -1--o bp cie DA_ ft PE Codes SC Info Received Cheek9/ Cash, , Amount Remitted Date i .. ParrnW Ice Request 9 Invoice ft , Well IDIt 437a is 3 r9teirf' *76,0 4-4.11 vl op END 43-06 6/11/2019 )-2-137..i-7 c- WELL /PUMP PERMIT