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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 />I4L/1V-KEFUNOA5LE rERM17 <br />JOB ADDRESS 7735 ST PT 99 <br />CROSS STREET Qantas Lane <br />OWNER NAME San Joaquin County <br />CourL House <br />OWNER ADDRESS <br />West Coast Exploration <br />PO Dox 133 <br />ADDRESS <br />WWW.S OV.Or sena CAI" i -1 TEAR FROM DATE ISSUED <br />CrTYR1P Stockton 95213 <br />17726010 , 17726014 304 ac <br />APN PARCEL SIZE LSrrD USE APPLICATION II <br />PHONE <br />CITYlSTATERIP Stocktcn, CA 95201 <br />209-985-7541 <br />PHONE <br />CITYISTATE/ZIP Escalon, CA 95320 <br />SUSCONTRACTOR/CONSULTANT ENGEO Incorporated - Jason Sedore PHONE 925-719-0822 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 17278 Golden Valley PF.Ny CITYISTATE/ZIP Lathrop, CA 95330 <br />LICENSE T1 C-57 O C-61 n D-09 n Other <br />BILLING PARTY: ❑ OWNER D CONTRACTOR <br />P, 70761 1/31/2022 <br />NUMBER EXPIRATION DATE <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) L DIbromochloropropane (4.392) D Arsenic (4393) <br />INTENDED USE D Domestic/Private L Irrigation/Agricultural O Industrial n Water Quality Monitoring D Soil Sampling/Characterization <br />D Public Water System <br />IF d,llerent from O.•.ner. Water System Name -- Contact Name or Phone Nimtor — <br />TYPE OP WORK rT New Well n Replacement Well ❑ Well Alleralbn/Modification O Other <br />O Monitoring Wells) H of wells ❑ Soll Boring(s) r auO1t"g0 177 Geotechnical <br />❑ Out-Of-Servlce Well D Out -Of -Service Well Renewal O Cross -Connection Repair <br />N or borings <br />Drilling Method ❑ Mud Rotary n Air Rotary O Auger D Cable Tool D Push Point 0 Other solid flight <br />Proposed Well Depth 25 It Excavation 4 In diameter ❑ Open Bottom D Gravel Pack/Gravel Size In diameter <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Schad L Steel D Plastic D Stainless Steel ❑ Other <br />Grout Seal Depth 25 h 19 Neat Cement (94 Ib bag/5-10 gal water) D Sand Cement sack m1Xr7 gal water <br />❑ Bentonile (20% solids) ❑ Other <br />Grout Placement Method D Pumped D Free Fall N Other t remie D Retardant f Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br />D Concrete Pedestal 0Dlmenslons: Width h Length R Thick In D Christy Box D Stove Pipe <br />PUMP O Submem le❑ Turbine _❑ Other H_PPump Set 4 Standing Water Level R_J <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 />MINIMUM 4/Qlu/OUR APYANCt NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7f)97 <br />SIGNED /J !` TITLE *rHOIQ1 Z1- -AC-64Vf DATE <br />To be determined. <br />Project boundaries <br />attached. <br />DEPARTMENT 3 SE ONLY <br />Appllcatlon Accepted By Dale (� , Z <br />Area / `1 Employee IDH 61o�,,y4o*, <br />Grout Inspection By <br />Date <br />lvl"12A <br />❑ SPECIAL Well Permit <br />Pump Inspection By <br />Dale <br />0 WAIVER Received <br />Soil Boring In action By <br />Dale <br />Constructed Well Depth <br />k <br />COMMENTS ��Clc'�-�Fr-G-I/Q/G% .cart' -//d `1 <br /><- <br />PE SC Received <br />Codes Into Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice H Well IDN <br />Service Re el: H <br />2 150 <br />4 2 <br />E4D41 M 8111:2019 WElUPW.IP PEPI.In <br />