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i <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1869 EAST HAZELTONAVENUE- STOCNrou CA 95205 -6232 (209)468-3420 <br />IYVIY-t[trUNUABLE PERMIT www.sjgov.org/elid <br />LAVIKLS 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 10027 Copperopohs <br />CITy/ZIp Stockton 95215 <br />CROSS STREET Best Rd APN 1030402VL <br />PARCEL SIZE 4 5 LAND USE APPLICATION III <br />OWNER NAME Jose Moreno <br />PHONE <br />OWNER ADDRESS 10027 Copperopolls Rd <br />CITYISTATE/ZIP Stockton, Ca 95215 <br />CONTRACTOR Golden State Inigabon E Pump Services <br />PHONE 209-943-7774 <br />CONTRACTOR ADDRESS 4500 E Fremont <br />- CITYISTATEIZIP Stocldon, W 95215 <br />SULTANT <br />ISUBCONTRACTORICONSULTANT ADDRESS <br />ENSE = C -S' D1C61 D D-09 <br />LING PARTY: = ONMER <br />CITYISTATE/ZIP <br />D Other NUMBER 979,533 <br />3 CONTRACTOR :: SUBCONTRACTORICONSULTANT <br />PHONE <br />EXPIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING:--. General MmeraVColdorm Bacteria (4391) Dibromochloropropane (4392) LI Arsenic (4393) <br />INTENDED USE Y Domestic/Private Cl lir gation/Agncultural G Industrial r; Water Quality Monitoring C Sod Sampling/Characterization <br />_ I Public Water System <br />If GRe mt from O«rrr Wafer System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well D Replacement Well C Well Alteration/Modification C Other <br />2MonRonngWell(s) Tirclwels ❑ Sod Bonng(s) 0dbwngs ❑Geotechnical •ofbonngs <br />G Out -Of -Service Well U Out -Of -Service Well Renewal c CrossConnectionRepair <br />Raise <br />Dnlling Method .i Mud Rotary C Air Rotary C Auger C Cable Tool -- Push Point C Other <br />Proposed Well Depth_ft Excavabon in diameter I: Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conductor Casing In diameter I Conductor Casing Depth It <br />Well Casing Diameter _ in ThicknesslGauge/ASTM Schetl C Steel C Plastic D Stainless Steel D Other <br />Grout Seal Depth R C Neat Cement (94 lb bagl5-10 gal rvaler) D Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) C Other <br />Grout Placement Method Z Pumped ❑ Free Fall D Other C Retardant / Acceterator (name) <br />I E <br />IDEST& Installed By G Driller C Pump Contractor ❑ Other <br />l C Concrete Pedestal CDlmensions Width ft Length It Thick in 7 Christy Box C Stove Pipe <br />PUMP IX Submersible? Turb,ne is Other HP 3 Pump Set 180 IT Standing Water Level 60 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 />Iftlt 1 1 <br />48 HOUR�yANCE NOTICE REQUIRED FOR I�jr CT NS - PLEASE CALL (209) 953 7`6_9`7 (�] <br />SIGNED M-1 �a ll `� 1 , TITLE . Wif�-jj� il�.��-I� DATE , l' tJ l% <br />EP RTMENT USE LY <br />Application Accepted By -�'� Date LZ Area Y <br />` Employee lD# <br />Grout Inspection By — D. (1 SPECIAL Well Permit <br />Pump Inspeacin By Date Ll WAIVER Received <br />Sod Boring I eNon By Dale i-. constructed WeVDppth 4 n ft <br />ENOWN-rara-im <br />LAX :. ►&;v.EXIII&M umewO-Mo IF <br />rru�aire dl varl■ /- -(/ X 1 `'s `% L' L -, <br />le l/ E> 11/ 2-2- <br />/ 2*t-I WELL (PUMP PERMIT <br />