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s `• � <br />473� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONktENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />INLJIN-KEFUNDABL E PERMIT WWW.sOv.Org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3199 N. Beecher Rd. 3 i g / n461: CITY/ZIP Stockton/95215 <br />CROSS STREETHM M 26 APN 089-11-013 PARCEL SIZE 20 LAND USE APPLICATION # <br />OWNER NAME Randy Sakakura __ PHONE 209-996-1496 <br />OWNER ADDRESS SAME CITYISTATEIZIP <br />CONTRACTOR -Delt-a_Pump Co. (Lbw -1 PHONE 20 9 6 6-962 5 <br />CONTRACTOR ADDRESS 646 S. California St. CITY/STATE/ZIP Stockton/95203 <br />�UBCONTRACTORICONSULTANT <br />i UBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATEIZIP <br />PHONE <br />LICENSE i C-5; X C-61 D-0�' Other NUMBER 11055434 EXPIRATION DATE 7131/2021 <br />BILLING PARTY: OWNER CONTRACTOR I SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: 1 General MineraUColiform Bacteria (4391) , Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTE r1D 12 USE - Domestic -'Private R IrrigationrAgricultural - Industrial Water Quality Monitoring r Soil SamplinglCharacterization <br />Public Water System r1A ` -_ <br />If d1`rerent from Owner. Water SYstern Name Contact Name or Phone Number i�H Y A —fir- <br />/f1- ri <br />TYPE OF WORK LI New Well I Replacement Well Well Alteration/Modification Other <br />fl Monitoring Well(s) # of wolls - Soil Boring(s) *,it bonn.3` r Geotechnical <br />I Out -Of -Service Well Out -0f -Service Well Renewal Cross -Connection Repair <br />New Pump -_ L Pump Replacement X Pump Repair _ Raise Well Casino <br />JUL 21 <br />'ENVIRpNM C� <br />Drilling Method J Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point _ Other HE ENT <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom i I Gravel Pack;Gravel Size 'Ln d arnd_ <br />J Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thick nessrGauge/ASTM Sched I I Steel Plastic i Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (941b bag/5- 10 gal wafer) _ Sand Cement sack rr; 7 gal water <br />i Bentonite (20% solids) I Other <br />Grout Placement Method _ Pumped U Free Fall - Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller - Pump Contractor Other <br />-1 Concrete Pedestal-IDimensions Width ft Length R Thick in Christy Box I Stove Pipe <br />PUMP SubmersibleX Turbine Other HP_QD Pump Set 160 It Standing Water Level 126 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 />lip f UR ADVANCE NOTICE REQ,�U(RED FOR INSPECTIONS - PLEASE CALL (2010t <br />slcNm 4� k -- -- - Tmt: CEO _ _ DATE 7/13/2021 <br />DEPARTMENT USE ONLY <br />Application Accepted ByL Date71,4 <br />Grout Inspection By_ _ Date <br />Pump Inspection By � Date <br />Soil Boring Inspection By Date 111 <br />COMMENTS <br />Area Employee IDttL) A <br />I SPECIAL Well Permit <br />_1 WAIVER Received <br />Constructed Well Depth <br />,M <br />m <br />D <br />v <br />T <br />Ty <br />4T <br />PE SC Received Check#/ <br />Codes Info as <br />Amount Pate, Permit/ Invoice # Well ID# <br />RemittedServi e e uest # <br />G1a esD <br />A -77Lf <br />EM1343-06 6t1U2019 sti3L (PUMP PF.32411r <br />