Laserfiche WebLink
ob 2 <br />SP_ jU R <br />NZH <br />WELL/PUMP PERMIT 14� / 'P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />YUN-KEFUNDABLE t'ERMIT CALL (LUV) V03-IbUt FUR INSNtCIIUN- CAYIKCJ"I TLAK I-KUM IJAI t I3JUtU <br />Jos ADDRESS 17880 West Schulte Road O <br />AZ, Tracy, California, 95377 <br />Mountain House PKWY <br />� /LAND <br />ROSS STREET APN <br />PARCEL $IZE7.2 ' USE APPLICATION # <br />OWNER NAME Costco Wholesale Corp. <br />ON, (209) 221-6200 <br />1,Z <br />OWNER ADDRESS 17880 W Schulte Road �q�'j� R /� <br />�� ITY/ TATE/ZIPr T acy;'�CA-795377 <br />-ONTRACTOR Moore Twining AssociatesPHONE <br />559-268-7021 <br />,'ONTRACTOR ADDRESS 2527 Fresno Street <br />CIN/STATE/ZIP Fresno, CA 93721 <br />SUBCONTRACTOR N/A <br />PHONE N/A <br />SUBCONTRACTOR ADDRESS N/A <br />CITY/STATE/ZIP N/A <br />-ICENSE X C-57 ❑ C-61 D D-09 ❑ Other <br />NUMBER 506159 EXPIRATION DATE 2/28/2019 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) J Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE ❑ Oomestic/Private D Irrigation/Agricultural ❑ Industrial Ll Water Quality Monitoring IJ Soil Sampling/Characterization <br />Li Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK IJ New Well J Replacement Well ❑ Well Alteration/Modification D Other <br />D Monitoring Well(s) # of wells C Soil Boring(s) # of borings X Geotechnical 2 # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />LI New Pump D Pump Replacement C Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method rJ Mud Rotary 0 Air Rotary AAuger C Cable Tool Li Push Point D Other <br />Proposed Well Depth 20 ft Excavation 8 in diameter D Open Bottom n Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad a Steel D Plastic J Stainless Steel ❑ Other <br />Grout Seal Depth ft X Neat Cement (94 /b bag/5-10 gal water) F- Sand Cement sack mix/7 gal water <br />Li Bentonite (20% solids) Ll Other <br />Grout Placement Method rXPumped D Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br />D Concrete Pedestal DDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submefslbleo Turbine D Other HP Pump Set ft Standing Water Level 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 COMPENSATION LAWS. <br />N HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76977 Q <br />SIGNED ( TITLE ��Ju-�-�^Kw� DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />4;ate <br />ENT U E O Late�Wre <br />Date <br />Date <br />Area Employee ID# <br />❑ PECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth ft <br />mmummimm�-MErn-mm I ' <br />EHD 43-06 8/01/16 <br />WELL /PUMP PERMIT <br />CE f VC D <br />iG <br />19 2018 <br />kL S4LTH <br />