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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 /> N <br /> JOB ADDRESS 1362 North Shaw Road CITY/ZIP Stockton,CA m <br /> D <br /> CROSS STREET E Fremont St APN 14326006 PARCEL SIZE 2.28 ac LAND USE APPLICATION# g <br /> } /' m <br /> OWNER NAME ()"ene '-,r-r)! t j�10 PHONE+. y <br /> OWNER ADDRESS 'q5 LI O bi fC1 l`1J n j_J(J`i(D �Q CITY/STATE21P �C K4on 95�'S' <br /> CONTRACTOR Neil O'Anderson and Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CrrYlSTATE/ZIP Lodi,CA 95240 <br /> SUBCONTRACTOR/CONSULTANT Same as above PHONE Same as above <br /> SUBCONTRACTOR/CONSULTANTADDRESS Same as above CITY/STATE/ZIP Same as above <br /> LICENSE X C-57 C-61 D-09 I i Other NUMBER #669004 ExPIRATION DATE 05/31/2023 <br /> BILLING PARTY: . OWNER X CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private irrigation/Agricultural Industrial .i Water Quality Monitoring )(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 i 1 Replacement Well 1 Well Alteration/Modification 1 Other <br /> Monitoring Well(s) #of wells Soil Bodng(s) a of borings �!Geotechnical 1 a or borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement _ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method !Mud Rotary ' Air Rotary )(Auger ! Cable Tool Push Point I Other <br /> Proposed Well Depth 15 ft Excavation 6 1/4" 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15 ft )<Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method XPumped ! Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller i Pump Contractor I i Other <br /> Concrete Pedestal i iDimensions:Width ft Length ft Thick in i Christy Box i 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 LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �9 TITLE Staff Engineer DATE 6/23/2021 <br /> 4!2 F <br /> 010 <br /> qN 3 221 <br /> 1 ENVgQU/ <br /> DEPARTMENT USE NLYY y LTy '�pMENT�N�. <br /> Application Accepted By /"— L Z' Dale Area / Employee ID# Rrue/vr <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection ByDate WAIVER Received <br /> c <br /> Soil Boring Inspection By nv Date Z/Constructed Well Depth ft <br /> COMMENTS Jr <br /> PE SC Received Chec Amount Date Permitl Invoice# Well ID# <br /> Codes Info By Remitted lavice Roquett# <br /> 3-7� 5 o �6 2 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />