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1504 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209068-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 6356 E. State Route 4 GITYIZw_Stockton/95215 <br /> CROSS STREETS. Gillis Rd APN 179-02-003 PARCEL SIZE231.94LAND USE APPLICATION# o <br /> A <br /> OWNER NAME _ _ PHONE 209-607-9229 �^ <br /> OWNER ADDRESS 1.8638 E. C_opperopolis Rd. _ _ CITYISTATEIZIP Linden/95236 <br /> CONTRACTOR De-Ita Pump Co. PHONE 209-466-%25 <br /> CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE I C-57 X C-61 D-09 Other NUMBER 1055434 EXPIRATION DATE 7i31i2021 <br /> BILLING PARTY: OWNER CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: -1 General MmeraUColiform Bacteria(4391) -1 Dibromochloropropane(4392)-1 Arsenic(4393) <br /> INTENDED USE -1 DomesticiPrrvate X IrrigationiAgricultural - Industrial Water Quality Monitoring IF Soil SamplingiCharacterization <br /> I Public Water System <br /> If different frerr Owrei. Water Systern Narnt: Contact Name or Phone Number <br /> TYPE OF WORK U New Well I Replacement Well Well Alteration.+'Modification Other <br /> q or-,. <br /> I'll Monitoring Wells) #of�.vells Soil Boring(s) of bnnngs I' Geotechnical # .,PA <br /> I Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair RFSME VT <br /> J Nevi Pum Pump Replacement -I Pump Repair Raise Well Casing _ <br /> WELL CONSTRUCTION J D <br /> Dnlling Method -, Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point Other UC 2 7 <br /> Proposed Well Depth fl Excavation in diameter I I Open Bottom i I Gravel Pack.Gravel Size $-�-,�eA in diaTZ <br /> Conductor Casing in diameter / Conductor Casing Depth It H IVV/R0 /N CD <br /> Well Casing Diameter_ in Thick ness'Gatige;ASTM Sched I i Steel Plastic I Stainless Steel Ot�A�THDE OEN/7�,,�� TY <br /> Grout Seal Depth ft _ Neat Cement(94 lb bag/S 10 gal water) _ Sand Cement sack mix.y gal wat'2t j <br /> Bentonite(20%solids) I' Other <br /> Grout Placement Method . Pumped J Free Fall _ Other r. Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller - Pump Contractor Other <br /> -1 Concrete Pedestal-IDimensions Width It Length R Thick in - Christy Box I Stove Pipe <br /> PUMP J SUbinersibleX Turbine Other HP_Q_O_ Pump Set J60 it 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 LAWS. <br /> M. `gANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL i2V' <br /> SIGNED _ � Tm.E CEO DATE 711412021 <br /> r <br /> N1 I <br /> r <br /> it <br /> � 8 <br /> Application Accepted By �/�`� Date 7 / Area < < Employee ID# <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date� �?� _ I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 4381 QACf 77 <br /> END 4.3 X W1 I!_019 WELL it UNf`r ER`AIT <br />