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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 />14Urv-Mtt-UNUAIJLt YtKMI I www.sigov.org/ona <br />tAY1Ktb I YEAR FROM DATE ISSUED <br />JOB ADDRESS 123 Van Derwin Parkway <br />CITY/Zip Stockton, CA <br />CROSS STREET Frank W Cir APN 193-370-02 <br />PARCEL SIZE 38 ac LAND USE APPLICATION# <br />OWNER NAME Scott Paris <br />PHONE <br />OWNER ADDRESS 3416 Newton Road <br />CITY/STATE/ZIP Stockton, CA, 95205 <br />CONTRACTOR Geo -Ex Subsurface Exploration <br />PHONE 916-799-8198 <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP Dixon, CA 95320 <br />SUBCONTRACTOR/CONSULTANT ENGEO Incorporated <br />PHONE 209-684-7604 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 17278 Golden Valley Parkway CITY/STATE/ZIP Lathrop, CA, 95330 <br />LICENSE x C-57 C-61 D-09 Other <br />NUMBER 954267 EXPIRATION DATE 10-30-20 <br />BILLING PARTY: OWNER ..CONTRACTOR <br />X SUBCONTRACTOR/CONSULTANT <br />DoMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x 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 x Other 4 CPTS <br />Monitoring Well(s) # of wells Soil Bonng(s) # of bonngs Geotechnical of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool x Push Point I Other <br />Proposed Well Depth 50-60 ft Excavation 4 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 50-60 ft x Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 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 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 COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ,I- /,- TITLE Staff Engineer DATE 08-26-19 <br />N <br />D <br />�&F"7 <br />VR ENT U I E O LY ��I - ,� <br />Application Accepted By ate Area Employee ID {`i�/rgJYJ <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />—.0—a .111L.0 <br />EHD 43-066 6/112019 //— ' � WELL (PUMP PERMIT <br />JriIRMJ�1/'�J�:��IF�E1�dJ611�►.I►.'l�!�!..'��.'J:M-a!J►�i.,� <br />Yw <br />—.0—a .111L.0 <br />EHD 43-066 6/112019 //— ' � WELL (PUMP PERMIT <br />