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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 255 W.Legacy Drive CITY/ZIP Mountain House,CA/95391 M <br /> D <br /> CROSS STREET Mercado Street APN 254-230-03 PARCELSIZE 1.38 LAND USE APPLICATION# o <br /> A <br /> OWNER NAME Manoj Vuriti and/or Chandra Sirapu PHONE 510.847.0805 m <br /> OWNER ADDRESS 800 Henley Court CITY/STATE/ZIP San Ramon,CA 94583 <br /> In <br /> CONTRACTOR V&W Drilling-Contact: Karli Stroing PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt,CA 95632 CD <br /> 7 <br /> tm <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/7JP <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2020 P <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT O <br /> C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) w <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System o <br /> Ir different from Owner: Water System Name Contact Name or Phone Number in <br /> N <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other (1 <br /> Monitoring Wells) #of wells Soil Boring(s) O of borings X Geotechnical 4 •of borings D <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 Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10-20 ft Excavation 4 1/2 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 full depth ft X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tremie i 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 /> MI M OUR IC T EQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 03/11/20 <br /> 1 <br /> N►ENr <br /> IVES <br /> 2 2020 <br /> IN COON?Y <br /> Fi FAERTMENT <br /> NTAL <br /> /, DEPARTMENT USE ONLY <br /> Application Accepted By ���r Date S//Z/,, Area S Employee ID# <<����►�� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By OP Date 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> nod <br /> SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Info Remitted Service Re uest# <br /> Jso 12 l lQ <br /> EHD 43-M 6/112019 WELL/PUMP PERMIT <br />