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t WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 96205 - (209) 468-3420 <br />r• NVI <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1271 and 1419 East Grant Line Road CITY21P Tracy, CA 95304 <br />CROSSSTREET MacArthur Dr APN 213-070-28/ 213-070-20 PARCEL SIZE 9'07 <br />18.88 Ac LAND USE APPLICATION # <br />OWNER NAME Helene A. Mattson / Bernardine M. Silva PHONE <br />OWNER ADDRESS 1291 East Grant Line Road/ 1419 East Grant Line Road CITY/STATE/zIP_ Tracy, CA 95304 <br />CONTRACTOR CPT, Inc PHONE (5101 357-3677 <br />CONTRACTOR ADDRESS 820 Aladdin Ave. CITY/STAWZIP San Leandro, CA, 94577 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CIOTY/STATEIzIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 8041327 EXPIRATION DATE 9/30/2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropene (4392) Arsenic (4393) <br />NTENDED USE DomesticlPdvate - Irrigation/Agricultural - Industrial Water Quality Monitoring x Soil Sampling/Characterization <br />Public Water System <br />If dxaerenl from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Wall Replacement Well - Well /Uteration,rMadiffcation . Other <br />Monitoring Well(s) # of Wells x Soil Boring(s) 'sof boongs x Geotechnical 7 It of bonrps <br />Out -Of -Service Well IOut-Of-Service Well Renewal Cross -Connection Repair <br />New Puma PUMD ReDlecement - Puma Renair Ralae Well CAainn <br />Drilling Method : Mud Rotary r; Air Rotary 7 Auger ' Cable Tool K Push Point Other <br />Proposed Well Depth 50 to 100 It Excavation 2 In diameter _ Open Bottom IGravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic - Stainless Steel Other <br />Grout Seal Depth ft it Neat Cement (94 Ib bag/5-10 gal water) - Sand Cement sack mixA gal water <br />Bentonite (20% solids) x Other boring backfilled with grout per county guidelines <br />Grout Placement Method Pumped x Free Fall I Other - 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 It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANE <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 963-7697 <br />SIGNED C--i�.ti TITLE President, RMO DATE 3/28/2018 ceu <br />P <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />y <br />m <br />D <br />m <br />YMENT <br />CEIVED <br />14 2018 <br />IOAQUIN COUNTY <br />MRONMENTAL <br />TH DEPARTMENT <br />CERM10 <br />IR 14 2018 <br />Cry IAL HEALTH <br />ZSERVICES <br />TMENT 7E O {j�Y <br />Date � p Are0SPECIALt <br />Employee ID#d��/,� <br />Date ll Permit <br />Date L WAIVER Received <br />Date Ponstructed Well Depth ft <br />r Tc V <br />PE Sc Received Check#1 Amount Permit/ <br />CodesInfo B Cash Remitted Date Service Request # Invoice # Well IDN <br />t7 <br />EHD43-06 M1116 <br />WELL !PUMP PERMIT <br />