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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />INvIN-r[Cr UNUADLE rtKmi I UALL ZUV) WSJ-tb97 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />123 Val Dervin Parkway <br />CITY/ZIP <br />Stockton/ 5206 <br />CROSS STREET <br />Frank W Circle APN 193-37-002 <br />PARCEL SIZE N/A-TAIO <br />USE APPLICATION # <br />OWNER NAME <br />American Honda Motor Co. <br />20 -983-4504 <br />OWNER ADDRESS <br />123 Val Dervin Parkway p <br />/, /srnre/ZIP <br />C(QPHHONE <br />ockton C06 <br />CONTRACTOR <br />Salem Engineering Group, Inc <br />PHONE (559) 271-9700 <br />CONTRACTOR ADDRESS 4729 W. Jacquelyn Ave. <br />cITYIsTATE21P <br />Fresno, CA 93722 <br />SUBCONTRACTOR <br />N/A <br />PHONE <br />ADDRESS <br />LICENSE XC -57 C-61 D-09 Other <br />CITY/STATE21P <br />NUMBER 970772 <br />EXPIRATION DATE 03/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X 31.999752 y -121.262133 Township _ Range Section <br />NTENDED USE Domestic/Private : Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different frim Owrwr: a er ys em ame ame or ria urn r <br />I YPE VF WORK New wen Replacement well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells XSoil Boring(s) 6 a °f bongs XGeolechnical 6 x of borings <br />Out -Of -Service Well - Out -0f -Service Well Renewal - Cross -Connection Repair <br />New Pumo _i Pumo Reolacement _ P—n Pow - D.;.. well ram,— <br />Drilling Method Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br />Proposed Well Depth 15-25 ft Excavation 4"-8" in diameter Open Bottom 1 Gravel Pack/Gravel Sizein 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 ft XNeat Cement (941b bag/5 10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method , Pumped XFree Fall X Other Trimmie - Retardant/ Accelerator (name) <br />PEDESTAL Installed By I Driller -1 Pump Contractor Other <br />Concrete Pedestal Dimensions: Width_ ft Length ft Thick in Christy Box Stove Pipe <br />PUMP 1 Submersibles Turbine , I Other HP Pump Sel ft 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 COMPENSATION LAWS. <br />- <br />MINIM R ADVANCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL (209) 95. 97 <br />SIGNED TITLE '�/� DATE 015 .V t <br />EPATMENT U E N Y <br />Application Accepted By Dale AreaEmployee ID# y��2 <br />Grout Inspection By . Date. C] SPECIAL Well Permit <br />Pump Inspection By)' eo�--v� Date L' WAIVER Received <br />Soil Boring Inspection By tf/Date GA. Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Check#/ Amount Date PermiU Invoice # Wall IDS <br />CoPNdes Info B Cash Remitted Service Request A <br />EMU 4] <br />4/ D/12 <br />WELL /PUMP PERMIT <br />