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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.sjgov.org/ena hAt'IKtS 'I YEAR FROM UATE ISSUED <br />Joe ADDRESS 26955 Hansen Road ,Rp G I I D 0 of CITYIZIP Tracy/95377 <br />CROSS STREET W Schulte Road APN 209-1140 '/ PARCEL SIZE 7.79 ac. LAND USE APPLICATION # <br />OWNER NAME The GF Irrevocable Trust Ku jVj.n n t j41 L' - T•` PHONE (209) 587-3200 <br />OWNER ADDRESS 2101 Park Warren Court CITY/STATE2IP Los Banos/CA/93635 <br />CONTRACTOR Salem Engineering Group, Inc. _ _ PHONE 559-271-9700 <br />CONTRACTOR ADDRESS 4729 W. Jacquelyn Avenue CITYISTATE21P Fresno/California/93722 <br />SUBCONTRACTORICONSULTANT Salem Engineering Group, Inc. <br />SUBCONTRACTORICONSULTANT ADDRESS 4729 W. Jacquelyn Avenue <br />PHONE 559-271-9700 <br />Cm/STATE/ZIP Fresno/California/93722 <br />LICENSE VC -57 C-61 D-09 Other NUMBER 970772 EXPIRATION DATE 3/31/2022 <br />BILLING PARTY: 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 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 Wells) # of wells /Soil Boring(s) 2 0 of borings Geotechnical 4 of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pumo PumD Reolacement PUmD Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br />Proposed Well Depth 20 to 30 ft Excavation 65/8 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 20 to 30 It /eat Cement (94 lb bag6-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped ree Fall Ather tremmie 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 _ <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 COMPENSATI LAWS. <br />MINIM U 8 OU VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE Geotechnical Staff Engineer DATE September 30, 2021 <br />U_1 <br />g <br />m <br />N <br />RFgYMF <br />o C�jVF T <br />RTTgCryT )' <br />MFNT <br />DEPARTMENT USE ONLY <br />Application Accepted By f�� Date 1 ID4 <br />Grout Inspection By A Data <br />Pump Inspection By Date t It <br />Soil Boring Inspection By Date <br />COMMENTS <br />As <br />Area S f C/ Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info <br />Check#/ <br />Cash <br />Amount to Permlt/ Invoice # Well ID# <br />Remitted Service Re uest # <br />37a <br />EHD 43-O6 61112019 /33-742723 WELL (PUMP PERMIT <br />