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1,;00 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT L ALL (LUV) U04-10tif FOR INSPECTIONS <br />tAYIKt.I T TEAR FRUM UAIE 155UEU <br />JOB ADDRESS 1271 and 1419 East Grant Line Road CITY/Zip <br />Tracy, CA 95304 <br />CROSS STREET MacArthur Dr APN213-070-28/ 213-070-20 PARCEL SIZE 1868 ACLAND USE APPLICATION # <br />OWNER NAME Helene A. Mattson / Bernadine M. Silva <br />PHONE <br />OWNER ADDRESS 1291 East Grant Line Road/ 1419 East Grant Line Road CITYISTATE/ZIP <br />Tracy, CA 95304 <br />CONTRACTOR Cuesta Geo / CK Construction <br />PHONE 925-872-1248 <br />CONTRACTOR ADDRESS 2709 Kapalua Court CITY/STATEIZIP <br />Fairfield, CA 94534 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE X C-57 D C-61 0 D-09 D Other NUMBER 903669 <br />EXPIRATION DATE -9-30-2019 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) L Dibromochloropropane (4392) L Arsenic (4393) <br />NTENDED USE n Domestic/Private n Irrigation/Agricultural n Industrial n Water Quality Monitoring X Soil Sampling/Characterization <br />Fl Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well D Replacement Well 0 Well Alteration/Modification D Other <br />D Monitoring Well(s) #of wells 9 Soil Boring(s) #of bonrtgs N Geotechnical 5 #of borings <br />A Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />D New Pump n Pump Replacement D Pump Repair n Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method D Mud Rotary 0 Air Rotary IX Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth 25 to 45 ft Excavation 6.5 in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad D Steel D Plastic D Stainless Steel D Other <br />Grout Seal Depth ft N Neat Cement (94 /b bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br />F1 Bentonite (20% solids) N Other boring backfilled with grout per county guidelines <br />Grout Placement Method D Pumped LX Free Fall D Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller n Pump Contractor n Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box D Stove Pipe <br />PUMP ❑ SubmersibleD Turbine D Other HP Pump Set ft Standing Water Level ft <br />T;r,' T nncnrocn 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />igitll <br />ay sid bChiK <br />gney rs rieg 3/23/18 <br />SIGNEDChri <br />DTITLE Owner DATE <br />DEPARTMENT USEONLY <br />_ �/V- <br />Application Accepted By Date -a a l / <br />Grout Inspection By - Date <br />Pump Inspection By Date -� '-- (w� <br />Soil Boring Inspection By Dale -�L <br />Area S r 4L Employee ID# ' `' r` " <br />LJ SPECIAL VV11e11 Permit <br />❑ WAIVER Received <br />Constructed Well Dept ft <br />J1QAQ1 U -,T.4r1>�v 4.-g3op <br />PE <br />Codes <br />Sc Received h <br />Info B ash <br />Amount <br />Remitted Date <br />PermiU <br />Service Request # Invoice # Well ID# <br />EH043-06 8/01/16 <br />WELL /PUMP PERMIT <br />fir <br />D <br />Y <br />