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as <br />4 • " WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1423 Bradford Street <br />CITY/LP Stockton, 95205 <br />CROSS STREET N. Wilson Way APN 117-150-19 <br />PARCEL SIZE LAND USE APPLICATION# <br />OWNER NAME Guggenheim Development Services <br />PHONE 916-969-7472 <br />OWNER ADDRESS 3000 Internet Blvd. Suite 570 <br />CITYISTATE/ZIP Frisco, TX 75034 <br />CONTRACTOR MatriScope Engineering <br />PHONE 916-375-6700 <br />CONTRACTOR ADDRESS 601 Bercut Street <br />CITY/STATE/ZIP Sacramento CA 95811 <br />SUBCONTRACTOR West Coast Exploration <br />PHONE 209-985-7541 <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/LP <br />LICENSE X C-57 D C-61 D D-09 I7 Other <br />NUMBER 870761 EXPIRATION DATE 01/31/2020 <br />PAY M <br />RECE <br />SUN � <br />sAN J""' <br />EW19 <br />�EAtTH <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 0 Arsenic (4393) <br />NTENDED USE a Domestic/Private ❑ Irrigation/Agricultural D Industrial D Water Quality Monitoring IR Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well D Replacement Well ❑ Well Mteration/M�odification D Other <br />D Monitoring Well(s) # of wells - Soil Boring(s) 'St- M of bodngst' yGeotechnicel > a of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ New PUMP D Pump Keplacemenl Ll Pump Kepair LI Haise Well casing <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rotary n Air Rotary Ii Auger i j Cable Tool f Push Point Other <br />Proposed Well Depth ft Excavation in diameter IOpen Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad i Steel Plastic 1 Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 lb bag/5-10 gal water) Sand Ce nt sack mW7 gal water <br />Bentonite (20% solids) Otger <br />Grout Placement Method Pumped Free dal Other flffi 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 SubmersibleD Turbine 17 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 NOTICE REQUIRED FOR INSPECTIONSt- PLEASE CALL (209) 953-7697 <br />SIG / TITLE 1'Q/V 7 G/✓6i.�VLf/� DATE ,TU1Vg -9 2Gl9 <br />D PARTMENT USE ONLY <br />Application Accepted By Dat Z`/ 001f <br />Grout Inspection B Date 19 <br />Pump Inspection By Date I 1 <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />'Crraw 5 <br />CEIVED <br />!N 13 2019 <br />IILNTAL HEALTH <br />ARTNIENT <br />Area Employee ID# <br />ECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />EHD 43-06 --d14114/18 <br />WELL /PUMP PERMIT <br />