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I <br />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.SIOOv.Ora/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />T <br />JOB ADDRESS Vicinity of Dad's Point at Louis Park CITy21P Stockton, CA 95203 m <br />D <br />CROSS STREET Monte Diablo Ave APN 133-060-01 PARCEL SIZE 60 ac LAND USE APPLICATION # o <br />m <br />m <br />OWNER NAME San Joaquin Area Flood Control Agency PHONE 209-937-8113 N <br />OWNER ADDRESS 22 E Weber Ave #301 CITY/STATEZP Stockton, CA 95202 L <br />CONTRACTOR California-Engiaeeri00.CootraeMrsine. t (, k Su��if1.�� fNce. (s r��1� PHONE '�'s x�'-'''` l /6' 7 �7 -�i <br />` <br />CONTRACTOR ADDRESS 2^u"AMU9 R^ d I T/V M(14 f7t V,/�tl.-y.e.. CITY/STATE/ZIP ) <br />SUBCONTRACTOR/CONSULTANT Geo -Ex Subsurface Exploration PHONE 916-799-8198 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1510 Madera Drive CITYISTATE/ZIP Dixon, CA 95620 <br />LICENSE X C-57 C-61 D-09 Other NUMBER 954267 EXPIRATION DATE 7/31/2020 <br />BILLING PARTY: X OWNER 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 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) # of borings K Geotechnical 5 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Haise Well <br />Drilling Method Mud Rotary Air Rotary Auger _ Cable Tool x Push Point Other <br />Proposed Well Depth 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 _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 90 ft X Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method k Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Wdth 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 />IN�O—TICE REQUIRED FOR <br />�I INSPECTLO - PLEASE CALL (209)))953-7697 <br />2) TITLE ! • t ^ Sr 1. y 7117 %i' Z ✓I�9`L)/ DATE L 6e,ZCJ <br />WENT <br />:CEIVED <br />T 2 3 2019 <br />)AQUIN COUNTY <br />(IRONMENTAL <br />H DEPARTMENT <br />8TMENT USO ON Y / <br />Application Accepted ByDate /)VI .1 Area oyee ID#�� <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection B Data Constructed Well Depth ft <br />COMMENT roc <br />7 i 7!I'7rNFAlliz11AMAl:L'!MUMFOAa1L'�[ <br />fr■ir����f��l� _� <br />EH043-M 6/112019 <br />WELL /PUMP PERMIT <br />