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a <br />4drre <br />w X <br />0- W <br />1-0 <br />�M <br />Mo �" <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNry ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEL TON A- NUT - STOCKTON CA 95205 •6232 12091 468-3420 <br />NON-REFUNDABLE PERMIT www.sigov.org/ehd _EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS California Avenue, see site plan @=J cl,Y;ziP Tracy 95304 <br />CROSS STREET El Rancho Road APN R=i PARCEL SIZE LAND USE APPLICATION R _ <br />OWNER NAME San Joaquin County, California _ P►toNE (209) 468 00 - _ <br />Ovi R AnoRESS 1810 East Hazelton Avenue cm/STAStockton, CA 95205 _ <br />CONTRACTOR Cale Crawford pttoae (209) 684-7605 <br />CONTRACTOR ADDRESS 17278 Golden Valley Parkway cm WATFJLPLathrop, CA 95330 <br />SUBCONTRACTOR/CONsuITANTMiddle Earth Geo Testing, Inc p,pM& (714) 633-5025 <br />SUBCONTRACTOR)CONSULTANT AOOR,Oe 954 North Lemon Street CITYISTATmP Orange, CA 92867 <br />LICENSE . GS.% C-61 D-09 OIhM NUMBlR 899451 ExPiRATimDATe 8/8/2020 <br />BN.LING PARTY: OWNER CONTRACTOR SVBCON7RAC70R/CON3ULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DomesbcJPrivate Irrigation/Agncuftural Industrial Water Quality Monitoring Soil SamplinglCharactenzabon <br />Public Water System <br />It ddlererl ire, Ovine• 'W.tei CgRed Name or Prro NuInher <br />TYPE OF WORK New Well Replacement Well VI&II Alterat,.on/Modrfication X Other <br />Monitoring Well(s1 a of wells r[iehJ 1 e er Dpf1i , X Geotechnical 2 • otennrgs <br />Out -01 -Service Well ut Df-SEEervli e ewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />well CONSTRUCTION <br />Dnlluig Method 61ud Rotary Au Rotary Auger Cable Tool XPush Point Other <br />Proposed Well Deptn 50 fl Excavation In diameter Open Bottom Gravel Pack!Gravel Size In diameter <br />Conductor Casing in diameter 1 Conductor Casing Depth it <br />Well Casing Diameter in Thickness+Gauge/ASTM Schad _ Steel Plasuc Stainless Steel Other <br />Grout Seal Depth "' ft XNeat Cement (94 to bal;6.10 gal water) Sand Cemen! sack mix,? gal waler <br />Bentonite (20% solids) Other _ <br />Grout Placement Method Pumped Free Fall Other -fiRetardant / Accelerator (name) <br />PEDESTAL Installed By Ddeer Pump Contractor Other _ <br />Concrete Pedestal Dimensions, Width_ N Length ft Thick to Christy Box Stow Pipe J <br />PUMP Submersible Turbine Other HP Pump Se; R Sta-sing Water Level It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUINC NTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT A ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COM NSATION LAWS. <br />,' R [)VAN NOTICE REQUIRED FZ I ,r,,EiTbN jCI�LI (209j8�-7bSi�� <br />SieseD TRC! <br />lSee attached For Site Plan I <br />D_E, ARTMENT SE ONLY <br />Application Accepted By _ Uale _ <br />Grout Inspection By <br />Pump Inspection By Dale <br />Sal Boring Inspection By __. Data <br />COMMENTS <br />" 2020 <br />A/7-�NTY <br />m � <br />�m <br />Arm -y� Employee IDK ASY` �—•I � � <br />PECIAL Well Permit y <br />WAIVER Received <br />Constructed Well Depth It <br />EHD43ee 6'110019 HELL -LDAP PERMT7 <br />