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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AvENUE-STocKrON CA 95205.6232(209)468-3420 <br /> NON-REFUND BLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS IV E`asltiel"Alexandria Place,50 ft north of intersection with W Lincoln Road CITY/7JP Stockton/95207 <br /> CROSS STREET W Lincoln Road APN Adjacent to 09711020 PARCEL SIZE n/a r LAND USE APPLICATION#n/a <br /> A <br /> m <br /> OWNER NAME City of Stockton PHONE 2099378212 y <br /> OWNER ADDRESS 425 N EI Dorado St CITYISTATEZP Stockton/CA/95202 <br /> CONTRACTOR ENGEO Incorporated PHONE 2098350610 <br /> CONTRACTOR ADDRESS 17278 Golden Valley Parkway CITY/STATEILP Lathrop/CA/95330 <br /> SUBCONTRACTORICONSULTANT West Coast Exploration,Inc. PHONE 2099857541 <br /> SUBCONTRACTORICONSULTANT ADDRESS P.O.Box 133 CRY/STATERIP Escalon/CA/95320 <br /> LICENSE a-57 ❑C-61 ❑D-09 []Other NUMBER 370761 EXPIRATION DATE 01/31/2022 <br /> BILLING PARTY: Fl-n- ❑✓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 E 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 Wells) #of wells ❑Soil Boring(s) #of borings Q Geotechnical I #of 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 ❑✓ Other Solid Stem <br /> Proposed Well Depth 30 ft Excavation 4 inches 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 entire depth 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 Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor 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 LAWS. <br /> MINIMUM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Lauren E Becker d — � TITLE Staff Engineer DATE 8/2/2021 <br /> ep a a <br /> E V�T <br /> FD <br /> Ile)A <br /> ?0?1 <br /> r q�Nrr <br /> MFHr <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Data Area G7 S 4Employee ID# INA <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection B r /y Date t ' Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ Invoice# Well ID# <br /> Codes Info P22, Cash Remitted Dat Service ReU <br /> 437a •S a-- <br /> EHD 4308 611112019 �^ /> ^� ^� A WELL/PUMP PERMIT <br />