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PHONE 209-481-5956 OWNER NAME Gene Caffese <br />CITY/STATE/ZIP Stockton, CA 95215 OWNER ADDRESS 5475 Van Allen Rd <br />EXPIRATION DATE 7/31/2021 LICENSE C-57 X C-61 D-09 Other NUMBER 1055434 <br />BILLING PARTY: OWNER CONTRACTOR I I SUBCONTRACTOR/CONSULTANT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT wvvw.sigov.orgIehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 6,1 061 1 S. Van Allen Rd. cingzip Stockton 95215 <br />CROSS STREET Oakwood APN 18-327-016 PARCEL SIZE 62 LAND USE APPLICATION # <br />CONTRACTOR Delta Pump, Inc <br />CONTRACTOR ADDRESS 646 S. California St. <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />PHONE 209-466-9625 <br />Ctiv/STATE/Zip Stockton, CA 95203 <br />PHONE <br />CITY/STATE/ZIP <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED UsE 1 Domestic/Private X IrrigationAgricultural - Industrial - Water Quality Monitoring I- Soil Sampling/Characterization <br />Public Water System <br />If different from Owrel Water System Name Contact Name or Phone Numb( • <br />TYPE OF WORK U New Well I Replacement Well Well Alteration/Modification Other <br />fl Monitoring Well(s) <br />11 Out-Of-Service Well <br />New Pump L Pump Replacement <br />- Soil Boring(s) # ot borings r Geotechnical # of Wrings <br />Out-Of-Service Well Renewal - Cross-Connection Repair <br />X Pump Repair _ Raise Well Casing <br />It of wells <br />HP 60 Pump Set 170 It Standing Water Level 100 It PUMP SubrnersibleX Turbine _ Other <br />ft Thick <br />PEDESTAL Other <br />ft Length in Christy Box II Stove Pipe <br />Installed By Driller Pump Contractor <br />-I Concrete Pedestal -IDimensions Width <br />WELL CONSTRUCTION <br />Dulling Method I Mud Rotary L, Air Rotary :1 Auger Li Cable Tool _ Push Point _ Other <br /> <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom II Gravel Pack:Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Plastic I Stainless Steel Other <br /> <br />Grout Seal Depth ft _ Neat Cement (94 lb bag/5-10 gal water) __ Sand Cement <br />i Bentonite 120% solids) I Other <br />Giout Placement Method Pumped U Free Fall Other L_ Retardant / Accelerator (name t <br />sack mtx17 gal water <br />in diameter <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 VV1TH ALL <br />WORKERS COMPENSATION LAWS. <br />MI, 8 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Tm_E CEO DATE 11/11/2020 <br />1111 WELL/PUMP PERMIT <br />DEPARTMENT USE ONLY <br />Application Accepted By--.—'?- --7-42.7—Zi.....-- Date iliOghx,› 0 <br /> <br />Grout Inspection By Date I SPECIAL Well Permit <br /> <br />Pump Inspection By 61.,1 _ r.S\ir (0,e^at, pu-o't Date 11(2-04-I I WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By, <br />Check#/ <br />Cash <br />Amount <br />Remitted Date <br />P-1(114) <br />Permit/ <br />rvice Request # <br />4041C1( a <br />InvoicePAYMEK ID# <br />"i.:: s7'I U"...-.) /'/27 7 Z3 3 477 RECEIVED <br />, <br />DEC -1- 0 2020 <br />c.i.....1 ineni ilkIrn1 INTY :SS32100V 311S fi / <br />Area Employee ID# <br />ft <br />El-ID 43-D6 Er1112019 ENVIRONMENTAL <br />HEALTH DEPARTMENT