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JOB ADDRESS 3212 N. California Street <br />Crry/Zip <br /> Stockton 94602 <br />CROSS STREET E. Sonoma Avenue APN 12532001 PARCEL SIZE 0.38 LAND USE APPLICATION # <br />OWNER NAME Catherine A. Bevanda dba M.J. Bevanda Properties PHONE 205-951-9900 <br />OWNER ADDRESS 6731 Hemdon Place <br />CITY/STATE/Zip Stockton, Ca 95219 <br />CONTRACTOR Intertek PSI PHONE 510-434-9200 <br />CONTRACTOR ADDRESS 4703 Tidewater Avenue, Suite B <br />SUBCONTRACTOR/CONSULTANT V&W Drilling <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1113 Blackhurst Drive <br />LICENSE X C-57 C-61 D-09 Other <br />BILLING PARTY: OWNER CONTRACTOR <br />CITY/STATE/ZIP Oakland, Ca 94601 <br />NUMBER 720904 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE 209-469-7700 <br />CITY/STATE/ZIP Galt, CA 95632 <br />EXPIRATION DATE 4/30/2022 :SS32100V 31IS 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 X Soil Sampling/Characterization <br />Public Water System Manuel Uribe 925-435-4159 <br />If different from Owner: Water System Name Contact Name or Phone Number <br />New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Well Alteration/Modification Other <br />X Soil Boring(s) 2 - 25 ft Sot borings <br />X Geotechnical <br />Out-Of-Service Well Renewal <br />Cross-Connection Repair <br />Pump Repair Raise Well Casing <br />TYPE OF WORK <br /># of borings <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 25 ft Excavation % 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 Other <br />Grout Seal Depth ft Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall <br /> <br />Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor <br /> <br />Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level 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 L <br />VANCO.NOTI MINIMUM 48 H <br />SIGNED 1440 <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLEA-CA-C'P DATE I <br />s4 <br />tAri. <br />DEPARTMENT USEI ONLY <br /> <br />Application Accepted By 0 Date 3/11/2 <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By <br />COMMENTS <br />Area c2/51)<44 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />iByr, <br />ttae3eiN-5 Amount <br />Remitted D ate Permit/ <br />Service Regu_ast # A Invoice # Well ID# Cash j <br />4437‘; !SI) 14V- 37Zit P,DR 3.11 1-A OPOOLI ISH <br />EHD 43-06 6/11/2019 <br />60 ,5),RWig' <br />6 <br />/2/3 3