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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 <br />www.sjqov.org/ena LAPIKt5 'I YEAR FROM UATE ISSUED <br />1_ISS'` <br />IArch Road 9 SS -9 <br />ISD <br />Stockton, 95215 <br />JOB ADDRESS <br />f L,�1 <br />CITY/ZIP <br />CROSS STREET <br />New Castle APN <br />18111004 & 18111006 <br />PARCEL SIZE ?LAND USE APPLICATION # <br />Richard Poolls <br />OWNER NAME <br />PHONE <br />1111 Broadway, 3rd <br />Floor <br />Oakland, CA 94607 <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR West Coast Exploration <br />CONTRACTOR ADDRESS PO BOX 113 CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT ENGEO Incorporated (Randy Ludwig) <br />SUBCONTRACTOR/CONSULTANT ADDRESS 17278 Golden Valley ParkwayCITY/STATE/ZIP <br />PHONE 209-985-7541 <br />Escalon, CA 95320 <br />925-570-7771 <br />PHONE <br />Lathrop, CA 95330 <br />LICENSE XC -57 C-61 D-09 Other NUMBER 870761 EXPIRATION DATE 01/31/2022 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring XSoil 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 <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification Other <br />Soil Boring(s) # of borings XGeotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />h # of borings <br />INew rump rump Kepiacemenr rump Kepalr Kaise vveil Lasing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Solid F1ight <br />Proposed Well Depth 10-2-5 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 4— in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 12 5 ft X Neat Cement (94 Ib bag15-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Tr emi e 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />NI R °i I AMk ryg 2UIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />a �' iii v g <br />email=Ml I n711777c -,' TITLE Sr. Project Manager DATE 10/7/2021 <br />.SIGNED _ patr- �m�tA 07 1 1 2722-0700' <br />DEPARTMENT USE ONLY <br />Application Accepted By _--;;�Z_ L Date I O I30 d <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 1 q C1 Employee ID# � <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />0 <br />0 <br />0 <br />rn <br />m <br />rn <br />ur <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ Amount ate Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />761 <br />ISD <br />X13. ►� 2 <br />EHD43-06 6/11/2019/ Z216'? v'17 WELL/PUMP PERMIT <br />