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✓ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NL)N-KEFUNUABLE YE IT L ALL (ZUV? y03-10tif FOR INSPECTIONS tAFIKtZ1 1 TEAR FROM UATE ISSUED <br />JOB ADDRESS 750 West Lane <br />CITY/ZIP Stockton, CA 95210 <br />CROSS STREET Hammertown Drive APN 094-040-04 <br />PARCEL SIZE 2.06 ACLAND USE APPLICATION # <br />OWNER NAME Builders Exchange of Stockton <br />PHONE <br />OWNER ADDRESS 7500 West Lane <br />CITYISTATEIZIP Stockton, CA 95210/��1//�� <br />PHONE (`�w <br />12�Q OakmPad Parkwa <br />(.6HTItrtCTT.11t 14D9RE66 Y <br />CITY/STATE/ZIP <br />SIreCONTRACTOR Exploration GeoServices, Inc. <br />PHONE (408) 280-6822 <br />See6ONTRACTOR ADDRESS 1535 Industrial Avenue <br />CITYISTATEIZIP San Jose. CA 95112 <br />LICENSE X C-57 G C-61 ❑ D-09 ❑ Other <br />NUMBER 484288 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) L Dibromochloropropane (4392) _ Arsenic (4393) <br />NTENDED USE n Domestic/Private n Irrigation/Agricultural n Industrial n Water Quality Monitoring X Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Comact Name or Phone Number <br />TYPE OF WORK D New Well ❑ Replacement Well ❑ Well Alteration/Modification D Other <br />❑ Monitoring Well(s) # of wells K Soil Boring(s) 0 O bOn"9e Vo Geotechnical 3 #of borings <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ New Pumo Fl Pumn Reolacement Fl Pumo Renair Fl Raise Well Casino <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary IX Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 25 to 35 ft Excavation 8 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 G Steel ❑ Plastic ❑ Stainless Steel D Other <br />Grout Seal Depth ft TR Neat Cement (94 Ib bag/5-10 gal water) P Sand Cement sack mix/7 gal water <br />F1 Bentonite (20% solids) a Other boring backfilled with grout per county guidelines <br />Grout Placement Method D Pumped IX Free Fall Other / n Retardant / Accelerator (name) <br />PEDESTAL Installed By F1 Driller F1 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Li Dimensions: Width fl Length ft Thick in fl Christy Box 'D Stove Pipe <br />PUMP LI Submersible Ll Turbine LI Other HP Pump Set fl Standing Water Level 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, TATE AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND E WITH T AL1 RNI CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA LAW . <br />MINIMUM 2 OU VA NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED TITLE President DATE 11/14/17 <br />m <br />D <br />A <br />m <br />N <br />Grout Inspection By Date L JPtGIAL vveN rermlt <br />Pump Inspection By ZY, Date ❑ WAIVER Received <br />Soil Boring Ins ection By Date ConstruqjQ Well D pth ft <br />COMMENTS �%��' <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />iD■ <br />LTH <br />