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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/ena <br />tAt'IKtb l YEAR FROM UATE ISSUED <br />JOB ADDRESS (�,'%oa �,{j�(?✓opil i$ <br />CmfZP Stockton/95215 <br />CROSS STREET E Main Street APN 101-040-22 <br />PARCEL SIZE 86.45 LAND USE APPLICATION # <br />OWNER NAME Stockton East Water District <br />PHONE 209-946-7543 <br />OWNER ADDRESS 6767 E Main Street <br />Cm/STATE/ZP Stockton/CA/95205 <br />CONTRACTOR Blackburn Consulting <br />PHONE 916-375-8706 <br />CONTRACTOR ADDRESS 2491 Boatman Ave <br />Cm/STATE0P West Sacramento/CA/95691 <br />SUBCONTRACTOR/CONSULTANT Taber Drilling <br />PHONE 916-371-8706 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 536 Galveston Or <br />Cm/STATEZP West Sacramento/CA/95691 <br />LICENSE C-57 C-61 D-09 Other <br />NUMBER 969927 EXPIRATION DATE 2/26/2022 <br />BILLING PARTY: OWNER j CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED WE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If d0went rra Omer Water System Name Contact Name a Phone Nurnber <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) a °I b0f1t9s / Geotechnical O a d borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary ; Auger Cable Tod Push Point Other <br />Proposed Well Depth_ 25 _ft Excavation 7 in diameter Open 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth_ 20'o;J It , Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other_ Backfill upper 5 feet <br />Grout Ptacement 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 It Standing Water Level ft <br />1 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 O <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALQtr <br />WORKERS COMPENSATION LAWS. }• <br />UM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76971SA/y Jp' <br />SIGNED TITLE Executive Vice President DATE 07.09.2021 F/V I poNM COUNT <br />pFPARTENTY <br />DEPARTMENT USE ONLY <br />Application Accepted By i� X L L Date '71---i <br />7 C Area f Employee ID# 1%�S <br />Grout Inspection By ✓ Date =2 SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By patet� Constructedlell Depth ft <br />Date <br />! Invoice S <br />Well IDS <br />EHD 43-05 6111,7079 /] _ '� � � / I � � WEU �IPUMP PERMIT <br />7 76 <br />