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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 />1NUIV-KEFUNUABLE PERMIT GALL (ZUU) 9b3-f69f FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 397 E. Ramsey Drive CITYIZIP Mountain House / 95391 <br />CROSS STREET Parco Avenue APN 209-450-38 PARCEL SIZE 16 AC LANE) USE APPLICATION # N/A <br />OWNER NAME Mountain House Community Services District PHONE N/A <br />OWNER ADDRESS 2030 S. Sterling Drive, Suite 100 CrTY/STATEIZIP Mountain House, CA 95391 <br />CONTRACTOR PHONE <br />t ADDRESS CrTY/STATEIZIP <br />:TOR Taber Drilling PHONE 916-371-8234 <br />:TOR ADDRESS 536 Galveston Street CRYISTATEIZIP West Sacramento, CA 95691 <br />X C-57 C-61 - D-09 = Other NUMBER 969927 EXPIRATION DATE 2/28/2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE _ Domestic/Private C Irrigation/Agricultural - Industrial 0 Water Quality Monitoring Soil SamplinglCharacterizalion <br />Public Water System <br />If daferem from Owner Water System Name COMA t Name of Phone Number <br />TYPE OF WORK -: New Well C Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells - Soil Boring(s) a of borings X Geotechnical 13 x or bonNs <br />Out -Of -Service Well __ Out -Of -Service Well Renewal = Cross -Connection Repair <br />New Pump it Pump Replacement Pump Reoair Raise Well Casino <br />Drilling Method Mud Rotary L Air Rotary X Auger .- Cable Tool _ Push Point :_ Other <br />Proposed Weft Depth 15-20 ft Excavation 6" in diameter - Open Bottom = Gravel Pack/Gravel Size in diameter <br />Boring L 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 15-20 It X Neal Cement (94 lb bag6-10 gal water) C Sand Cement sack fn/x17 gal water <br />Bentonite (20% solids) f_ Other <br />Grout Placement Method X Pumped _ Free Fall - Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal _Dimensions: Width it Length it Thick in 7 Christy Box Stove Pipe <br />PUMP Submersible:- Turbine Other HP Pump Set it Standing Water Level H <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 />DEPARTMENT USE ONLY <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#I Amount Date Perm)tl Invoice It Well ID# <br />Codes Info By Cash Remitted Service Request <br />uest # <br />EHD 43-06 &OV16 WELL /PUMP PERMIT <br />N <br />m <br />D <br />0 <br />A <br />m <br />N <br />