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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONAtENTAL HEALTH DEPARTMENT 1868 EAar HAZELTON AVENUE - STOC/CTON CA 95205 -6232 (209)4684420 <br />NON-REFUNDABLE PERMIT bwrw.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />J06 ADDRESS <br />CROSS STREET Da Vinci Drive APN 11002004 <br />2628 W. March Lane <br /> <br />PARCEL SIZE • c1C-LAND USE APPLICATION <br />CtrfIZIP Stockton, CA 95207 <br />404-765-8036 <br />OWNER NAME Chick-61-A, Inc. PHONE <br />OWNER ADDRESS 5200 Buffington Road CITY/STATE/ZIP Atlanta, GA 30349 <br />PHONE 714-279-0817 <br />CONTRACTOR Gdes Engineering Associates <br />CONTRACTOR ADDRESS <br /> <br /> CITY/STATFJZJP Orange, CA 92865 1965 N Main Street <br />PHONE 916-524-1270 Cal Nev Geoexplorabon , Inc. SUBCONTRACTOR/CONSULTANT <br />1079 Sunrise Avenue Roseville, CA 95661 SUBCONTRACTOR/ CONSULTANT ADDRESS CITY/STATE/ZIP <br />NUMBER 1039188 5/31/2021 <br />LICENSE X-57 C-61 D-09 . Other EXPIRATION DATE <br />OWNER "CONTRACTOR _ SUBCONTRACTOR/CONSULTANT Baleen PAarr: <br />Oomesftc WELL SAMPUNG: - General Mineral/Coliform Bacteria (4391) Dibromochlorepropane (4392) - Arsenic (4393) <br />INTENDED USE _ Domestic/Private Inigation/Agricultural _ Industrial _ Water Quality Monitoring Irsoil Sampling/Characterization <br />_ Public Water System Conted Name or Phone Number Water System Name If different from Owner <br />Type OF WORK _ New Well _:. Replacement Well _ Well Alteration/Modification _ Other <br />_ Monitoring Well(s) 8 of wells . Soil Boring(s) Rot D'n",* allirGeotechnical 6 • ot wrings <br />- Out-Of-Service Welt - Out-Of-Service WeN Renewal - Cross-Connection Repair <br />Raise Well Casino Merl rui lp • <br />WELL Coftsrftucftoft <br />Drifting Method - Mud Rotary - AM Rotary )(Auger - Cable Tool - Push Point - Other <br />Proposed Well Depth ft Excavation In diameter _ Open Bottom _ Gravel Pack/Gravel Size in diameter <br />_ Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in ThicknessiGauge/ASTM Sched _ Steel _ Plastic _ Stainless Steel _ Other <br />Grout Seal Depth 20 ft jr Neat Cement (94 lb bag/5-10 gal water) _ Sand Cement <br />_ Bentonite (20% solids) _ Other <br />Grout Placement Method - Pumped - Free Fall 3 Other Tremie - Retardant / Accelerator (name) <br />sack mix/7 gal water <br />PEDESTAL Installed By Driller - Pump Contractor <br />- Concrete Pedestal -Dimensions: Width <br />Other <br />It Length ft Thick - Christy Box - Stove Pipe <br />_ Submersible _ Turbine Other HP Pump Set ft Standing Water Level ft PUMP <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953'Y' <br />SIGNED <br />4/13/21 4/13/21 <br />Trite DATE <br />SEE ATTAZ,H ED 3IT: P _AN %MTh BO RIN .0C All ON <br />17 CA/ <br />TMENT U <br />Application Accepted By / 4:1 411111,' <br />Grout Inspection By ..-e=7 <br />a Employee ID* <br />_ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br /> ft <br />Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checker <br />,Cash <br />Amount <br />tqemittedi Date : i <br />Permit/ <br />ice Request it_., Invoice 0 Well 1111/ <br />Or- I cl) <br />19_ <br />7 Vi-s6L-- .fliat-f-phi21 AIT''bUti-V- IN <br />EHID 43-06 BPI I /2019 <br />d.obl. /)_+01 73 <br /> WELL /PUMP PERMIT