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t <br /> t <br /> WELL/PUMP PERMIT <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 <br /> P NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 W Lincoln Road-N Pershin -Ave to Alexandria P U1 crrymp Stockton/95207 LA <br /> CROSSSTREET N Pershing Ave APN_07 Ol �C'-r ARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME City of Stockton PHONE y <br /> OWNER ADDRESS 425 N EI Dorado.Street crTYisTATE/ZIP Stockton,CA 95202 <br /> CONTRACTOR Taber Drilling PHONE 916-371-8234 <br /> CONTRACTOR ADDRESS 536 Galveston Street crry/sTATE/LP West Sacramento,CA 95691 <br /> SUBCONTRACTOR/CONSULTAW BSK Associates PHONE 925-315-3151 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 252 W. Larch Rd,Suite H CITY sTATE/ZIP Tracy,CA 95304 <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 969927 EXPIRATION DATE 02/28/2022 <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 k Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ower. 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 Boring(s) N of borings X r cP technical_6_4 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 10-30 It Excavation 6-8 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth a-3 �XNeat Cement(24 lb baa/5-1.0 tvaLW_ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �v <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED (9ma)L l� <br /> TITLE Project Geologist DATE 7/13/2021 <br /> 3EEA TAC E SITEP At IyR <br /> F'iYJV NT <br /> Fp <br /> 00"V <br /> DEPARTMENT USE ONLY I w 'Q <br /> Application Accepted By Date 7 2 Area S k�N Employee ID# t,V`7 <br /> Grout Inspection By i DateWWA SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date t Constructed Well Dep ft <br /> COMMENTS Wtt♦� P O <br /> d <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Caph, Remitted i Re uest# <br /> 4 ISO ISI <br /> EH043-06 6/11/2019 n /293���� WELL/PUMP PERMIT <br />