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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 /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRES;)Ie21 Z11440%11 CA(GPS: 37.985167. -121.483528) _ CITY2IP�/ Stockton CA 95206 <br /> CROSS STREET Ct.1k,717 111 Zuckerman Rd)APN C PARCEL SIZE Z/LAND USE APPLICATION# <br /> OWNER NAME �Q of Ctrr4fn.. kru I(fit (24 ;y bet(_,},,�JQ( HONE l N <br /> OWNER ADDRESS 1,__t7�Jr�--� I_`'© 9 CITY/STATE/ZIP +�` ��',/ <br /> CONTRACTOR Underground construction Co. PHONE 707-741-1761 <br /> CONTRACTOR ADDRESS 5145 Industrial Way CITY/STATEIZIP Benicia,CA 94510 <br /> SUBCONTRACTORICONSULTANT Compro Companies Inc.., PHONE 510-5094993 <br /> SUBCONTRAC`TOORICONSULTANT ADDRESS 2625c Barrington Court CITY/STATE/ZIP Hayward Ca 94545 <br /> ♦ <br /> LICENSE C-57 C-61 D-09 Other NUMBER 764878 EXPIRATION DATE 06/30/2021 <br /> BILLING PARTY: OWNER CONTRACTOR VAUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other G Well <br /> Monitoring Well(s) #of wells Soil Boring(s) If of borings Geotechnical #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 /> WELL CONSTRUCTION <br /> Drilling Method VIMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 300 ft Excavation 81, in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesyGauge/ASTM Schad Steel Plastic Stainless Steel Other No Casing <br /> Grout Seal Depth_100 —ft Neat Cement(941b bagl&10 gat water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other 100'-3'NEAT CEMENT <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing 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 /> 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 48 HOUR ADyANqE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �/' TITLE Construction Manager DATE 10/01/2020 <br /> YMFNT <br /> E <br /> Cel wEr, <br /> �T 28 2020 <br /> �AQUIN C <br /> M 0 PARTM NT <br /> DEPARTMENT [IRF ONl Y <br /> Application Accepted By G� Dat- � RArea � Employee ID# DA <br /> Grout Inspection By Date, t'-.% I U320 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS \Oe C- l,C (—Co � <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted S e Re u s # <br /> EHD 43-06 6111/2019 � ` //����T� WELL(PUMP PERMIT <br />