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WELL/PUMP PERMIT 15 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1271 and 1419 East Grant Line Road cm9zlP Tracy, CA 95304 m <br /> D <br /> CROSS STREET MacArthur Dr APN 213-070-28/213-070-20 PARCEL SIZE <br /> 9.07 18-88 Ac LAND USE APPLICATION# 0 <br /> m <br /> OWNER NAME Helene A. Mattson/Bernardine M. Silva PHONE rn <br /> OWNER ADDRESS 1291 East Grant Line Road/1419 East Grant Line Road CITY/STATE/ZIP Tracy CA 95304 <br /> CONTRACTOR CPT, Inc PHONE (650) 346-1490 <br /> CONTRACTOR ADDRESS 104 Constitution Drive, Suite 2 CITY/STATE/ZIP Menlo Park, CA, 94025 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE a C-57 L C-61 a D-09 ❑Other NUMBER 884827 EXPIRATION DATE 09/30/2020 <br /> DOMESTIC WELL SAMPLING:'. General Mineral/Coliform Bacteria(4391)_ Dibromochloropropane(4392)1_Arsenic(4393) <br /> INTENDED USE n Domestic/Private n Irrigation/Agricultural n Industrial F Water Quality Monitoring X Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK U New Well I I Replacement Well I-Well Alteration/Modification D Other <br /> LI Monitoring Well(s) #of wells X Soil Borings) �of bO""9s k.Geotechnicalof borings <br /> ft <br /> ❑Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> n New Pump n Pump Replacement n Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool K Push Point ❑ Other <br /> Proposed Well Depth 50 to 100 ft Excavation 2 in diameter a Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F 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 rX Neat Cement(94/b bag/5-10 gal water) F1 Sand Cement sack mix/7 gal water <br /> F] Bentonite(20%solids) IX Other boring backfilled with grout per county guidelines <br /> Grout Placement Method ❑Pumped 1X Free Fall U Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller n Pump Contractor fl Other <br /> I Concrete Pedestal:Dimensions:Width ft Length ft Thick in ❑Christy Box I:1 Stove Pipe <br /> PUMP U Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> MINIMUM 24 HOU�RyADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED "^'� �� TITLE RMO DATE 10/10/2018 <br /> Nil. <br /> �Fo <br /> o �N�X018 <br /> �T 0N�Y <br /> MFh'T <br /> EPA TMENT US O L <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date LJ SPECIAL ell Permit <br /> Pump Inspection By Date L1 WAIVER Received <br /> Soil Boring Inspection By, �ivt r 4�}1V�P7� Date "7"��� Constructed Well Depth ft <br /> COMMENTS D`ZRt,/u� C,('T� (`.t?TN�P,(`�C-V2. CPTV1 <br /> PE sC Received Amount Da Permit/ Invoice# Well ID# <br /> Codes Info Cash mixed Service Re uest# <br /> TZU <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />