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WELL/PUMP PERMIT 1< /t <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 23500 Kasson Road crryaiP Tracy/ 95376 <br />PE SC Received Check#I Amount Permit) <br />Date Invoice # Well ID# <br />CROSS STREET Mancusso Rd APN 23912001 PARCEL SIZE LAND USE APPLICATION It <br />rh Service Request # <br />Codes Info B as <br />OWNER NAME State of California PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR Kleinfelder PHONE (209) 948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite #100 CITY/STATEIZIP Stockton/ CA/ 95206 <br />SUBCONTRACTOR V&W Drilling PHONE 209-469-7700 <br />SUBCONTRACTOR ADDRESS 3806 Duck Creek Dr CIN/STATE/ZIP Stockton/CA/95215 <br />LICENSE V C-57 -1 C-61 ] D-09 ❑ Other NUMBER 720904 EXPIRATION DATE 4/30/20 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ] Domestic/Private ] Irrigation/Agricultural 'I Industrial ] Water Quality Monitoring -1 Soil Sampling/Characterization <br />] Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK -1 New Well ] Replacement Well ] Well Alteration/Modification ] Other <br />] Monitoring Well(s) # of wells ] Soil Bodng(s) a of borings j� Geotechnical 4-6 a of borings <br />] Out -Of -Service Well ] Out -Of -Service Well Renewal ] Cross -Connection Repair <br />] New Pump Pump Replacement ] Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method )(Mud Rotary ] Air Rotary ] Auger ] Cable Tool ] Push Point ] Other <br />Proposed Well Depth 10-50 ft Excavation 6-8 in diameter ] Open Bottom ❑ Gravel Pack/Gravel Size in 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 />_ <br />Grout Seal Depth ft )( Neat Cement (94 Ib bag/5-10 gal water) ] Sand Cement sack mix/ ater <br />�V <br />71 Bentonite (20% solids) :1 Other <br />Grout Placement Method -1 Pumped ] Free Fall XOther ] Retardant / Accelerator (name) <br />PEDESTAL Installed By 7 Driller ] Pump Contractor -1 Other <br />] Concrete Pedestal ]Dimensions: Width ft Length ft Thick in ] Christy Box ] Stove Pipe <br />PUMP ] Submersible"1 Turbine -1 Other HP Pump Set ft Standing Water Level <br />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 COMPENS�A ON LAWS. <br />MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED_ �7��--=-'y/�-` / - TITLE Staff Geologist DATE 6/11/2018 <br />Application Accepted By <br />Grout Inspection BX <br />Pump Inspection By <br />m <br />D <br />A <br />m <br />N <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />EHD43-06 8101/16 ��1 / �/-��� WELL /PUMP PERMIT <br />V1.5v t;4 <br />PE SC Received Check#I Amount Permit) <br />Date Invoice # Well ID# <br />rh Service Request # <br />Codes Info B as <br />EHD43-06 8101/16 ��1 / �/-��� WELL /PUMP PERMIT <br />V1.5v t;4 <br />