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JOB ADDRESS 3651 Arch Rd cirazip Stockton/CA <br /> <br />PARCEL SIZE I 79 Acres LAND USE APPLICATION # <br /> PHONE <br />CITY/STATE/ZIP Encinatas/CA/95023 <br />Jivtesh S. Gill <br />OWNER ADDRESS P 0 Box 235927 <br />CROSS STREET 99 E Frontage <br />OWNER NAME <br />ApN 179-48-007 <br />West Coast Exploration Inc PHONE 209-985-7541 CONTRACTOR <br />CONTRACTOR ADDRESS P0 Box 133 CITY/STATE/ZIP Escalon/CA/95320 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Ave Ste 150 CITY/STATE/ZIP Modesto/CA/95356 <br />Er CONTRACTOR SUBCONTRACTOR/CONSULTANT BILLING PARTY: 0 OWNER <br />Water System Name Contact Name or Phone Number <br />INTENDED USE C Domestic/Private 0 Irrigation/Agricultural CI Industrial 0 Water Quality Monitoring X Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: <br />in diameter <br /> <br />Proposed Well Depth 8.5 ft Excavation 4 inches in diameter 0 Open Bottom E Gravel Pack/Gravel Size <br /> <br />E Conductor Casing in diameter / Conductor Casing Depth ft <br /> <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth Y.- .:j.• ft M Neat Cement (94 lb bag/5-10 gal water) E Sand Cement sack rnix17 gal water <br />E Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped H Free Fall C.: Other Retardant / Accelerator (name) <br />Installed By 0 Driller P Pump Contractor C Other <br />0 Concrete Pedestal 0Dimensions: Width ft Length ft Thick <br />PEDESTAL <br />in 0 Christy Box C Stove Pipe <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392) 0 Arsenic (4393) <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings R Geotechnical 2 Sot borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />PUMP HP Pump Set ft Standing Water Level ft 0 Submersible P Turbine 0 Other <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool C Push Point P Other <br />SUBCONTRACTOR/CONSULTANT CTE Cal Inc PHONE 209-543-1799 <br />LICENSE C-57 E C-61 0 D-09 Other NUMBER 870781 EXPIRATION DATE 1/31/2022 532100V 311S Ic VVELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALQ1 DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON -REFUNDABLE PERMIT www.slgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /P-a-41t441 <br />BE A T A <br />ENT <br />WED <br />6 2021 <br />N COUNTY <br /> MENTAL <br />PARTMENT <br />TITLE Staff Geologist DATE 2/12/2021 <br /> PAY M <br />RECE <br />F81 <br />SAN JOAQU <br />EWIRON <br />HEAL111-1 Dt <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />DEPARTMENT USE ONLY <br /> Date • i/14 Area /2 Employee ID# <br />Date.?...)N277-- SPECIAL Well Permit <br />Date = WAIVER Received <br />Soil Boring Inspection By , gate Constructed Well Depth ft <br />COMMENTS )11,74' /.-A e f), p r 4 f , <br />PE <br />Codes <br />SC <br />Info <br />Rece'ved Checkl# <br />Cash <br />Amount <br />Remitted Date Permit/ Invoice # Well ID# <br />Li..., /...,. i,.,-) at*4 1,6- I- C,,-, 'E-. 4 •1\49 - 21 <br />Servipe6RTii-stpo ,,, <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT