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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206-(209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 150 N. Sinclair Ave C1TY/ZIP Stockton 95215 <br /> CROSS STREET E. Myrtle St APN 159-020-10 PARCEL SIZE LAND USE APPLICATIONX <br /> OWNER NAME KTD, LLC PHONE 916-583-3902 9 <br /> OWNER ADDRESS 8531 Thys Court CITY/STATEMP Sacramento, CA 95828 <br /> CONTRACTOR US PUII Test PHONE 818-625-1300 <br /> CONTRACTOR ADDRESS 2713 Georgette PI / CITY/STATE/ZIP Simi Va�lleJy,C A 930637-'''j�J/� <br /> SUBCONTRACTOR -Y 1 ! Iv PHONE /� // G' <br /> SUBCONTRACTOR ADDRESS 01@L`410CITY�/STAT� Ll <br /> CJ67 S~ <br /> C- <br /> LICENSE 57 C-61 D-09 Other NUMBER 0 ! <br /> EXPIRATION DATE v <br /> DOMESTIC WELL SAMPLING:..General Mineral/Coliform Bacteria(4391) _ Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestictPrivate --Irrigation/Agricultural :_Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It dlferent hom Owner: Water System Nemo Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well --Well Afteration/Modification Other <br /> Monitoring Well(s) 0 of wells X Soil Boring(s)_ e of bonngs JC Geotechnical I e or 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 Rota Air Rotary XAuger - Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation 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 Silted Steel Plastic Stainless Steel ..Other <br /> Grout Seal Depth1;E It >iKest Cement(941b bag/5-10 gal water) Sand Cement sack mix/1 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Viumped _Free Fall Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions Width it Length ft Thick in Christy Box ::Stove Pipe <br /> PUMP Submersible- Turbine 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, STAT" , AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTT TH THE CA F IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMPENS TIO LAWS. <br /> I U H U ADVANCE OTICE REQUIRED F IIN/ FCTIQNS- CALL(209)9$3-76971 <br /> 510N DATE <br /> P"L-6���� <br /> SI <br /> qR <br /> 0 y ?019 <br /> ADY-1 JOLI '1iZA RD ASN Cp <br /> I r --— OFpq���TY <br /> D P TIENT USE/ /ONLY� <br /> Application Accepted By Date7� �0� Area Employee IDe ✓�� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sal Boring Inspection By ate Constructed Well Depth R <br /> COMMENTS - i <br /> PE SC Received Check#/ Amount Date PermiU Invoice a Well IDk <br /> Codas Info Cash Remitted Service uestN <br /> 7 <br /> EHD 43-W rewsee 4114/1e �y��2-1D WELL'PUMP PERMrr <br />