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SO'S <br />MpR 1 <br />PERMS <br />WELL/PUMP PERMIT r'/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />ry UIV-Ktt-UNUAbLt F'LKMI I <br />1:133-I113tll FOR INSPECTIONS tAFIKtZ1 l YEAR FROM DATE ISSUED <br />ADDRESS <br />25800 McIntire Road _/ <br />CITY/ZIP Clements/95227 <br />SS STREET <br />Hwy 12 APN 023-01-001 <br />PARCEL SIZE 1,027 LAND USE APPLICATION # <br />IER NAME <br />East Bay Municipal Utility District'A(� <br />PHONE 510-287-1619 <br />IER ADDRESS <br />375 11th Street / � x - 6 o <br />���- 6666 <br />CITY/STATE/ZIP Oakland, CA 1i4ee7`- `7 `%VZ - 3 <br />TRACTOR <br />Salem Engineering Group, Inc <br />PHONE (559) 271-9700 <br />TRACTOR ADDRESS 4729 West Jacquelyn Avenue <br />CITY/STATE/ZIP Fresno, CA 93722 <br />CONTRACTOR <br />Salem Engineering Group, Inc <br />PHONE (559) 271-9700 <br />SUBCONTRACTOR ADDRESS 4729 West Jacquelyn Avenue CITY/STATE/ZIP Fresno, CA 93722 <br />LICENSE XC -57 C-61 _ D-09 - Other NUMBER 970772 EXPIRATION DATE 03/31/2020 <br />GEOGRAPHICAL INFORMATION: Coordinates X 38.228945 Y -121.022170 Township_ Range Section <br />NTENDED USE -Domestic/Private _ Irrigation/Agricultural F Industrial - Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If differem from Owner. Water System Name Contad Name or Phom Number <br />TYPE OF WORK New Well Replacement Well r- Well Alteration/Modification i'" Other <br />Monitoring Well(s) # of wells XSoil Boring(s) 4 # of borings XGeotechnical 4 # of borings <br />Out -0f -Service Well L Out -Of -Service Well Renewal I. Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary XAuger 1 Cable Tool Push Point Other <br />proposed Well Depth 15 ft Excavation 4"-6° in diameter _ Open Bottom , Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad - Steel F Plastic F Stainless Steel 1 Other <br />Grout Seal Depth ft XNeat Cement (94 lb bag15-10 gal wafer) i Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I Other <br />3rout Placement Method i Pumped (Free Fall C Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 1 Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />Pu MP 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 />MINIMYM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 95 -7697 <br />SIGNED�� TITLj�J �JIN�ATE <br />N <br />V1 <br />LVED <br />2 3 20% <br />:N"ESL IIt-:kLl'li <br />RVNIENY <br />Application Accepted By / AfEP <br />RTMENT YSE PN Y <br />` Date <br />Area Employee ID# <br />4e 1 <br />Grout Inspection By <br />Date <br />SWell Permit <br />Pump Inspection By <br />Date <br />- WAIVER Received <br />Soil Boring Inspection ByDate <br />`f`� <br />Constructed Well Depth <br />ft <br />COMMENTS <br />PE SC Received <br />Codes Info B <br />heck Amount Date Permit/ Invoice # Well ID# <br />ash Remitted Service Request # <br />EHD 43-08 WELL /PUMP PERMIT <br />4/30112 <br />