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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 /> 2758 E.Woodbridge Road Acampo/95220 U1 <br /> JOB ADDRESS CITY/ZIP <br /> Hidden Lake Lane 01323008 32.6 ac. o <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> JIMLyV�Lc�CCT � NOWNER NAME BalJit Mathfallu PHONE (209)483-5254� A <br /> 1.11 <br /> OWNERADDRESS 24234 Cherokee Lane CITY/STATE/ZIP Galt/CA/92543 <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE (559)271-9700 <br /> CONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue CRY/STATE/ZIP Fresno/CA/93722 <br /> SUBCONTRACTOR/CONSULTANT Salem Engineering Group,Inc. PHONE(559)271-9700 <br /> SUBCONTRACTORICONSULTANT ADDRESS 4729 W.Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> LICENSE VC-57 C-61 D-09 Other NUMBER 07 EXPIRATION DATE 03/31/2022 <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 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 Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells /Soil Borings) 2 #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary //Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15-25 It Excavation 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 15-25 ft /Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped N/Free Fall /Other Tremmie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It <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 COMPENSIrION LAWS. <br /> MINIMU 8 H=OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Geotechnical Staff Engineer DATE June 16,2021 <br /> RFq yMF <br /> cF�V or <br /> U <br /> N <br /> ?0?� <br /> A*I q�NTY <br /> MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 4fn:: Date 1 a Area •L//q�� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By — Date WAIVER Received <br /> Soil Boring Ins action By Date 0, j Constructed Well Depth ft <br /> COMMENTS C 'r' ,- O 4 V Eti/P <br /> PE SC Received Chii Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 437.7 r.08' <br /> EHD43-06 6/11/2019 i/ . �2Z-71-39-8 WELL/PUMP PERMIT <br />