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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 /> f- <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 472 and 410 Airport WayManteca/95337 T <br /> Joe ADDRESS CITY/ZIP m <br /> D <br /> CROSS STREET Crom Street APN 200-130-010-000 PARCEL SIZE 13.20""LAND USE APPLICATION# o <br /> m <br /> OWNER NAME <br /> KB HomePHONE s/Jessica Camarena 909-229-8112 m <br /> L <br /> OWNER ADDRESS 4830 Business Center Drive Sune 150 O I STATEZP Fairfield/California/94534r <br /> Mid Pacific En eerin 916-927-7000 <br /> CONTRACTOR 9'^ 9 PHONE <br /> CONTRACTOR ADDRESS 840 Embarcadem Drive suite 20 CITY/STATEZP West Sacramental California/95605 <br /> v a w Drnnng <br /> SUBCONTRACTOR PHONE 209-369-9600 <br /> SUBCONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATEZP Gait/CA/95632 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 7.0964 EXPIRATION DATE 4/30/2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of bpnngs X Geotechnical 5 #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 XMud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 2.56;1x10;2.15 ft Excavation 8 Inches 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 1°; 15:50 ft X Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width ft 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, 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 /> NIM/JUM 48HOURVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7797 <br /> SIGNED,I ✓/ r rs- / TITL a l:lei% / / /�Jv/ DATE <br /> fl <br /> �4 <br /> O <br /> X0C. <br /> 4 <br /> Nco <br /> pgRN 44 <br /> ke <br /> R M E N T U VE N L Y <br /> Application Accepted B Date Area Employee ID# <br /> Grout Inspection By Data PECIAL Well Permit <br /> Pump Inspection By ff''rr7 Date WAIVER Received <br /> Soil Boring Inspection By ( lJ'L1 Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received CAmount D to Permit/ Invoice# Well ID# <br /> Codes Into ash miffed Service Request# <br /> EHD 43-06 revised 4/14/18 �/1� ri � / / J WELL/PUMP PERMIT <br />