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)®� '�>�t�3�' <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 (209) 4&8-3420 <br />NUN-KEFUNDQDABLE PERMIT CALL {209) 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FRom DATE IssuEo <br />JDoADoReesR'DI Shulte Road --- 'Tracy, CA 95304 —a <br />CITY/ZIP <br />eRosssrRSEr Chrisman Road 250 -180 -ID j 5 1�, 3 <br />APN PARCEL SIX£ LANn USE APPLICATION AR <br />OWNER NAME R $ R Fame Management, LLC PHONE 510-825-1620 <br />OWNER ADDRESS 1012 Scorpion Place C1TYISTATEfZ(P Fremont, CA 94539 <br />CONTRACTOR Magglora Bros. Drilling, Inc_ PHONE 831-724-1338 <br />CONTRACTOR ADDRESS 595 Airport Blvd. CITY/sTAMZJP_ Watsonville, CA 95076 <br />1SU8CONTRACTOR ADDRESS <br />LIcEN8E X C-57 X C-61 D-09 <br />Other <br />CITYISTATE ZIP <br />NUMBER 249957 <br />PHONE <br />EXPIRATION DATE 09-30-19 <br />. ? B 77 <br />N PJDED tJsF DolnestiGPrivato X IrrigationlAgr cultural in Water Quality Monitoring Soil Sampling/Characterization <br />Public Water Syystem <br />If dlfferenf from 0 finer: er y .um Name on ecl Name or Poona Number <br />F LPE OF M'ORK New Well Replacement Well Well Adteration/Modification Other _ <br />Monitoring Well(s) # of wells Soil Boring(s) 0 o borings Geotechnical #of bodngs <br />Out -OF -Service Well Out-Of-ServiceWell Renewal Cross -Connection Repair <br />X New PumD Pumn Raolacemant Pumn raennir Rniia 1At.11 Cacinr-. <br />Drilling Method ' Mud Rotary Air Rotary Auger Cable Tool Push Point Other _ <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PackJGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/GaugelASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (941b bag/5-10 gal water) Sand Cement sack mia17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fail Other Retardant /Accelerator (name) <br />rJELSTAL Installed By Driller Pump Contractor Other <br />C Concrete Pedestal , Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submarsible Turbine Other HP t3O Pump Set _ ft Standing Water Level 5 ft <br />f HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORD 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 HOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />U) <br />�m <br />m <br />z� <br />0 <br />m <br />4 <br />E,ORTI'.1ENT S E ONLY <br />Application Accepted ByJV2 <br />Date <br />Grout Inspection By Date <br />Pump Inspection By Date 0 <br />Soil Boring Inspection By Date <br />COMMENTS O <br />Area Employee 04A9t5CSi"J <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received hec <br />Codes Info Cash <br />Amount Date Permit/ Invoice # <br />Remitted Service Re uest # <br />Well ID# <br />6 g <br />15 IWP60,3195, <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />