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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 />NUN-KEFUNDABLE PERMIT -www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JoB ADDRESS 22197 E. Serenity Ct. CITY21P Linden, CA 95236 <br />CROSSSTREET S. Hewitt Rd APN 183-370-280-000PARCr6 ELSIZELAND USE APPLICATION# <br />OWNER NAME PTIJ17 G7P_ct_ct Porn — ger} ; Cheryl kJP-,fS4e yo / n PHONE <br />OWNER ADDRESS �e-M11 i2(LI, CITYISTATE/ZIP Linden, CA 95236 <br />CONTRACTOR BSK Associates PHONE 209-769-4734 <br />CONTRACTOR ADDRESS 550 W Locust Avenue CRYISTATEIZIP Fresno, CA, 93650 <br />SUBCONTRACTOR/CONSULTANT BSK Associates PHONE_ 209-769-4734 <br />SUBCONTRACTORICONSULTANTADDREss550 W Locust Avenue CIry1STATE21PFresno, CA, 93650 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 490942 EXPIRATION DATE 12 / 3 1/ 2 0 2 1 <br />BILLING PARTY: OWNER XCONTRACTOR 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) o of borings X Geotechnical 4 X 15 ' s of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 15 ft Excavation 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 1,5' It X Neat Cement (941b bag/5-10 gat water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) X Otherboring will be backfilled with neat cement to approx Z below grade and cuttings over that since farml <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED_ —�J TITLE Principal Professional / C-57 RME DATE9/22/2021 <br />n,�nrl;r,�� <br />DEPARTMENT USE ONLY <br />Application Accepted By Data 'Z I Area Z `% ! Employee ID# / r / J <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Data WAIVER Received <br />Soil Boring Inspection By Date ���� Constructed Well Depth ft <br />COMMENTS <br /># Invoice # I Well ID# <br />10 <br />EHD43-06 611112019 (/ ' �'-' 43 <br />/q3 ,/57/ WELL /PUMP PERMIT <br />►ENT <br />IVED <br />2021 <br />COUNTY <br />ENTAL <br />RTMENT <br />