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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 wviw.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1515 S Fresno Avenue Crrvizip Stockton, CA 95206 <br />CROSS STREET Navy Dr APN 16337034 PARCEL SIZE 36.28 LAND USE APPLICATION SS <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Neil 0 Anderson and Associates <br />CITY/STATE/Z/P <br />PHONE (209) 588-2219 <br />PHONE <br />ONTRACTOR ADDRESS 902 Industrial Way <br />CITY/STATE/ZIP Lodi, CA 95240 <br />SUBCONTRACTOR/CONSULTANT Same as above <br />ptfoyaE Same as above <br />UBCONTRACTORICONSULTANT ADDRESS Same as above CITY/STATE/ZAP Same as above <br />CENSE X. C-57 C-61 D-09 Other NUMBER #669004 F., Dm, 05/31/2021 <br />BILLING PARTY: OWNER X CONTRACTOR . SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Con/owl Bacteria (4391) • Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br /> <br />II different from Owner Water System Narne <br />Contact Name or Phone Number <br />TYPE OF WORK . New Well Replacement Well Well Alteration/Modification Other <br />C Monitoring Well(s) # of wells Soil Bonng(s) Rot bonngs X Geotechnical <br /> 8 aol borings <br />0 Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />7- New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 <br />fi <br />Excavation <br /> <br />6 1/4" in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing indiam diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 n )( Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack frlixI7 gal water <br />Bentonite 120% solids) Other <br />Grout Placement Method ,'Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Width <br />Other <br /> <br />ft Length ft Thick in Christy Box Stove Pipe <br />1,261P Submersible Turbine Other HP Pump Set ft Standing Water Level ft <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 VV1TH 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_ / - <br /> <br />TITLE Staff Engineer DATE 5/6/2021 <br />Iff <br />AlA <br />Aqf C00A, 4. 2,47 <br /> <br /> <br />us <br />rea / <br />as <br />Employee IDS <br />SPECIAL Well Permit <br />Date -WAIVER Received <br />Date ) r, I Constructed Watt Depth ft <br />Application Accepted By <br />Grout Inspection By <br />Pu.7,::)leaction Sy <br />g tCr ng In ction y <br />MMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />,BAsA ljtfae <br />Amount <br />Remitted Date Permit/ <br />ust * Service R eqe WI invoice * W IDO <br />1,1- -47i 5-.D.-, - c2.3104SO i 5-0 6i--t NO0042011 <br />E110 d3-OE 611,2019 WELL /PUMP PERMIT