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R <br /> t <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 PARK '/V- vwvw.s gov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS Int r Ction of N.Potato Rd and N Williamson Rd crrY/LP Terminous/95242 LI)Ct, m <br /> D <br /> CROSS STREET Tower Park Way APN 05503015 PARCEL SIZE 28.8 aC LAND USE APPLICATION# o <br /> � A <br /> OWNER NAME SR) rt ('LL PHONE <br /> -' ( 7 . JOWNER ADDRESS 7Jl7L71 w <br /> CONTRACTOR Neil O'Anderson and Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATE/ZIP Lodi,CA 95240 <br /> SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Same as above CRY/STATEIZIP Same as above <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2023 <br /> BILLING PARTY: I OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <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 <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings X Geotechnical 1 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary 1 Air Rotary DQ Auger Cable Tool Push Point 1 Other <br /> Proposed Well Depth 50 it Excavation 6 1/4° in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 ft X Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method YPumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_.;, .� _ TITLE Staff Engineer DATE 6/1/2021 <br /> PAYMENT <br /> - RECEIVED <br /> JUN 0 4 2021 <br /> S N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> t LTH DEPARTMENT <br /> t _ ;• �je� <br /> DaPAq/rMENT U E NLY <br /> Application Accepted By J— Date/, ���I Area I Employee ID# " <br /> Grout Inspection Date' I 1 ECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permw Invoice# Well ID* <br /> Codes Info Cash Remitted Service Request 9 <br /> P <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br />