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195 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IMUIV-KEFUNDABLE PERMIT WWW.SJ Oy.Orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 2440 Leamed Ave. _ CITY/ZIPStockton/95205 <br />CROSS STREET Mariposa Rd. APN 173-02-020 -PARCEL SIZE 0.56 LAND USE APPLICATION # <br />OWNER NAME Gloria Prieto _ PHONE 209-323-9621 <br />OWNERADDRESS SAME CITYISTATE/ZIP <br />CONTRACTOR Delta Pump Co. PHONE 209-466-9625 <br />CONTRACTOR ADDRESS 646 S. California St. CrrYrSTATErztP Stockton/CA/95203 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />RACTOR/CONSULTANT ADDRESS <br />LICENSE i C -57 XC -61 D-09 Other <br />BILLING PARTY; OWNER CONTRACTOR <br />CITYISTATE/ZIP <br />NUMBER 1055434 EXPIRATION DATE 7/31/2023 <br />LI SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: -1 General Mineral/Coliform Bacteria (4391) -1 Dibromochloropropane (4392) -1 Arsenic (4393) <br />INTENDED USE Domestic/Private F1 Irrigation/Agricuttural - Industrial -1 Water Quality Monitoring f- Soil Sampling/Characteriz*on <br />Public Water System A va -� <br />-- f ddferent from Owner Water Systwn Name Contact Name or Phone Number 21" <br />tTYPE OF WORK ! New Well i Replacement Well Well AlterationfModification Other <br />1 L <br />1 Monitoring Well(s) # of wells -Soil Boring # of borings s) r Geotechnical 1 <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair % <br />I New Pum Purn Replacement ] Pum Repair Raise Well Casin `SBA/ ✓Q 2022 <br />WELL CONSTRUCTION HEq� IRON COU <br />71 <br />Drilling Method Mud Rotary L Air Rotary U Auger U Cable Tool _ Push Point _ Other TN pEP EIS TIO lN// <br />Proposed Well Depth_ft Excavation in diameter I I Open Bottom I I Gravel PacktGravel Size In d <br />ConmetL <br />- Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter _ in Thick ness•Ga uge,ASTM Sched I I Steel Plastic I i Stainless Steel Other <br />Grout Seal Depth ft _ Neat Cement (941b bags 10 gal wafer) _ Sand Cement sack rmx!7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method _ Pumped U Free Fall _ Other U Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Purnp Contractor - Other <br />-1 Concrete Pedestal ]Dimensions- Width 111 Length R Thick in Christy Box fl Stove Pipe <br />PUNm XSubmersible_ Turbine Other HP 1.5 Pump Set 110 ft Standing Water Level - ft <br />I HEREBY CERTIFY THAT 1 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 />14':► - ' ` '+ ;' _ UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (208) 9`^ " <br />SIGNED qMW___ TITLE CEO DATE,21?n- <br />8 <br />2420 <br />j-ZA.�' F' <br />MIL Y ;'AIM <br />• � T <br />Application Accepted By Date <br />Grout Inspection By Date Q <br />Pump Inspection By-'i��\� Date <br />Soil Boring Inspection By Date <br />COMMENTS t '-C- Lv C1 �(? ' )1n w I/ Inc 1,' Gi I <br />Ir <br />Area _ LnIL-„y,. ,f:+,' <br />I SPECIAL Well Permit <br />I WAIVER Received <br />COIISt1UCled Well Depth f( <br />PE <br />Codes <br />SC Received ChS&kW <br />Info ash <br />Amount Dae <br />Remitted <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Well ID# <br />381 <br />0 <br />! <br />o� <br />PAYMFNT <br />-- <br />--_ <br />-- <br />EHD 43-06 6I1 t120I9 <br />- � � <br />HELL lPUN'P PERMIT <br />JAN 0 3 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />Lail Ar TLL}' <br />