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f <br /> 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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 1139 S.Garden Avenue CITYI7JP Stoekton/95205 <br /> CROSS STREET E Guernsey Avenue APN 157-150-130 PARCEL SIZE 1.86 ac-LAND USE APPLICATION# o <br /> M <br /> OWNER NAME Angelo Leandro PHONE 209-601-2251 y <br /> OWNER ADDRESS 5992 E.Highway CIT//STATEZP Stockton/CA/95215 <br /> CONTRACTOR Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 W.Jacquelyn Avenue Crry/STATE/ZIP Fresno/CA/93722 <br /> SuBCONTRACTOR/CONSULTANT Salem Engineering Group,Inc. PHONE 559-271-9700 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4729 W.Jacquelyn Avenue CIT/ISTATE/ZIP Fresno/CA/93722 <br /> LICENSE JC-57 C-61 D-09 Other NUMBER 970772 EXPIRATION DATE March 31,2022 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private rrigation/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 /> MonitoringWell(s) #of wells /SoilBoring(s) 1 #ofbonngs 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 50 It Excavation 6 5/8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 50 It JNeat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 71tFree Fall Other tremmte 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 It 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA ON LAWS. <br /> MINIM 4 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Geotechnical Staff Engineer DATE July 15,2021 <br /> Ar e <br /> E FNS <br /> ee atl adie, 9 2021 <br /> / NCO <br /> RTS��ry <br /> 7- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �- /� Date 71/4:qd I Area Employee ID# <br /> Grout inspection By Date SPECIAL Well Permit <br /> Pump Inspection By ^ / Date WAIVER Received <br /> Soil Boring Inspection By ♦ / V _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Dat Permit! Invoice# Well ID# <br /> Codes Info ash Remitted Service a uest# <br /> H S <br /> EHD 43-06 611112019 / 2J fta 8L3 WELL/PUMP PERMIT <br />