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WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1898 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4883420 <br /> NON-REFUNDABLE PERMIT _CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7759 S.Airport Way CrTY77JP Stockton,CA <br /> yy��r D <br /> CROSS STREET - APN�� V�7 �� PARCEL SIZE LAND USE APPLICATIONS A <br /> OWNER NAME San Joaquin County Mosquito PHONE <br /> OWNER ADDRESS 7759 S.Airport Way CITYISTATEMP Stockton,CA <br /> CONTRACTOR Var:;n a Nssuuatcs,is1c. P"oW 559.348.2200 <br /> CONTRACTOR ADDREss 215 W.Dakota Avenue CrTT/STATE7ZIP algornla 93612 <br /> SUBCONTRACTOR r-an&Associates,Inc. Piton 559.348.2280 <br /> SUBCONTRACTOR ADDREas 215 W.Dakota Avew Crtv/STATE2v As,California 93612 <br /> LICENSE ./C-57 D C-61 0 D-09 C Ogler NUMBER ExPIRAnoN DATE 10.31.2021 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibramochloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE 0 DOmeSUC/Private ;1 Inigation/Agricultural 7 industrial ,Water Quality Monitoring n Soil Sampling/Characterization <br /> 0 Public Water System <br /> 1k§ff entfa Owner Water System Name Cent dName"Phone Nnb. <br /> TYPE OF WORK 0 New Well Replacement Well 0 Well Ateration/Modihcation D Other <br /> 0 Monitoring Well(s) A of wells D Soil Bonng(s) a 0 bongs Z Geotechnical 4 e of borings <br /> F1 Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connecdon Repair (15-50 Feet) <br /> u New Pump L,Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary D Air Rotary r/Auger Z Cable Tool C Push Point = Other <br /> Proposed Well Depth /S"-5i4 ft Excavation in diameter 7 Open Bottom C Gravel PadUGravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Srhed Steel Plastic Stainless Steel C Other <br /> Grout Seal Depth ft V Neat Cement(941b bag 10 gai wafer) =Sand Cement sack mfx17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method o Pumped f 1 Free Fag Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By L Driller _Pump Contractor D Other <br /> L Concrete Pedestal r7Dimenslom:Width fl Length ftThick in L.Christy Box r-Stove Pipe <br /> PUMP D Submersible?Turbine D Other HP Pump Set It Standing Water Level it <br /> 1 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 URA A GEMOTICE REQUIRED FOR INSPEC"TIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TIITLE "Aarr:rtinc Fn�ir'^r DATE 11.19.2020 <br /> ! <br /> AY <br /> MENT <br /> ECEIVED <br /> C 0 9 2020 <br /> I <br /> _ _ ___ _ OAQUIN COUNTY <br /> '1 1RONMENTAL <br /> DEPARTMENT <br /> 7 <br /> i I <br /> I L A I <br /> I <br /> I I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By .r '�-�i� Date ?,RIO P(JV Area `' Employee IDF� <br /> Grout Inspection By I Data ❑ SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Checw Amount PermiU <br /> Codes Into B Cash Remitted Date ervica Request0 invoked WeU IDp <br /> EHD 4346 nvh d"tuts WELL HUMP PERMn <br />