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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 ADDRESS Southeast corner of Corral Hollow Rd and Middlefield Dr C,Ty/Z,P Tracy,CA 95377 <br /> m <br /> D <br /> CROSS STREET Corral Hollow Rd APN 24402031 PARCEL sIZE10.97 aCLAND USE APPLICATION# o <br /> C t m <br /> OWNER NAME J I teem yPHONE y <br /> OWNER ADDRESS t2Sd FM i)y C_ CITY/STATE/ZIP nia.,rA)kAlh flDU-`.(, qS3 q. <br /> CONTRACTOR Neil(T Anderson Ad Associates PHONE (209)588-2219 <br /> CONTRACTOR ADDRESS 902 Industrial Way CITY/STATE/71P Lodi,CA 95240 <br /> SUBCONTRACTORICONSULTANT Same as above PHONE Same as above <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Same as above CITY/STATE/ZIP Same as above <br /> LICENSE kC-57 C-61 D-09 Other NUMBER #669004 EXPIRATION DATE 05/31/2021 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private F 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 i Replacement Well E Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells r Soil Boring(s) #of borings �`Geotechnical 2 #of borings <br /> Out-Of-Service Well F Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing P <br /> WELL CONSTRUCTION R <br /> Drilling Method Mud Rotary Air Rotary 1(Auger Cable Tool G Push Point Other <br /> Proposed Well Depth 15 to 20 ft Excavation 6„ in diameter 7 Open Bottom - Gravel Pack/Gravel Size in diameter F/�'�Y <br /> Conductor Casing in diameter / Conductor Casing Depth ft AO <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel -1 Plastic Stainless Steel Other <br /> Grout Seal Depth 5 t0 20 ft X Neat Cement(94 lb bag/5-10 gal water) -Sand Cement sack mix/7 gal ` ?O <br /> Bentonite(20%solids) Other 0q QV/ �O <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator name IRO /V C <br /> Installed By Driller Pump Contractor Other Ty0 Pq�N q�NJ y <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> T <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft RTMFN <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED-l�-,,��( TITLE Staff Engineer DATE 8/21/2020 <br /> J2 r <br /> J2 r' <br /> r <br /> i <br /> DEPARTMENT USE NLY Y <br /> Application Accepted By � Date y V� Area l69L Employee ID# S^ <br /> Grout Inspection By Date_ SPECIAL Well Permit <br /> Pump Inspection By oc Date f r WAIVER Received <br /> Soil Boring Inspection Byate Constructed Well Depth ft —I <br /> OMMENTS ; 1It f i181Qof r2r' Pipe 1-C CJP . <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 43 7a 5 C of <br /> EHD 43-06 6!1112079 ���_�� /' //�O� / J� WELL/PUMP PERMIT <br />