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WELL/PUMP PERMIT <br />SAN JOAcium COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 1868 EAST HAZELTON AVENUE - STaeKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS 5648 N EI Dorado Street CITYlZtP Stockton 195207 <br />SS STREET E Robinhood Drive APN 102.090.01 pARCELSIZE 26.11 Ac LAND UsE APPucATtoN # <br />IER NATE Saint Mary's High School PHONE 209-957-0861 <br />IER ADDRESS 5648 N. EI Dorado Street CITY/STATE17jp Stockton, CA 95207 <br />Geo-Engineenng Solutions, Inc. <br />CONTRACTOR ADDRESS 2570 San Ramon Valley Blvd <br />r— California Geotech <br />:TOR ADDRESS 6886 Village Parkway <br />PHONE 925-215.7789 <br />CITY/STATE/ZIP San Ramon, CA 94583 <br />PHONE 831-634-1964 <br />CrTY/STATE/ZIP Dublin, CA 94568 <br />LICENSE X C-57 CIO1 0-09 Other NUMBER 812382 EXPIRATION DATE 9/30/2020 <br />DOMEsmC WELL SAMPuNG: 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 />N different from O=err Water System Name Contact Name or Phone Number <br />TYPE OF WORN New Well - Replacement Well Well Alferation/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) _ aotbonrps X Geotechnical 4 ___a of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />. New Pump Pump Replacement Pump Repair Raise Well Casing <br />RFrRetir <br />CieewD <br />Pro <br />2 2 2019 <br />OROu/N COON <br />.TH p p� MINT <br />7� ��]D��/tRTMENT USE O �/y� <br />Application Accepted By / ✓ V Date � l�i Area_ __ l/ Employee ID# <br />Grout Inspection Date SPECIAL Well Permit <br />Pump Inspection B Date _ WAIVER Received <br />Soil Boring InspectioQ6 Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 reread 411VIS WELL /PUMP PERAtn <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool 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 <br />Well Casing Diameter _ in Thickness/Gauge(ASTM Sched _ Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb ba915-10 gal water) Sand Cement_ _ _ _ -. _ _ sack mixA gal water <br />.: Bentonite 120% solids) '. Other <br />Grout Placement Method .. Pumped Free Fag Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width R Length it Thick in - Christy Box Stove Pipe <br />PUMP_ :Submersible Turbine Other HP Pump Set Standing Water Level <br />_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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH TH ALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO <br />M:NICfUCJI �3 ZA NCF 101ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091953-7697 <br />SIGNED TntE����il _,r�- DATE -rte <br />RFrRetir <br />CieewD <br />Pro <br />2 2 2019 <br />OROu/N COON <br />.TH p p� MINT <br />7� ��]D��/tRTMENT USE O �/y� <br />Application Accepted By / ✓ V Date � l�i Area_ __ l/ Employee ID# <br />Grout Inspection Date SPECIAL Well Permit <br />Pump Inspection B Date _ WAIVER Received <br />Soil Boring InspectioQ6 Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 reread 411VIS WELL /PUMP PERAtn <br />