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�� -nihal / 3 <br /> Scan 5-h2-IPW fib <br /> WELLMUMP_PERMIT /�3� :3� --)/�y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT ARTMENT._ -'T HAZELTON AVENUE-STOCKTON CA 95205-(20 )46 3420 <br /> • NON-REFUNDABLE PERMIT CALL 200 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> f Joe ADDRESS 26301 Hansen Road CRr21P Tracy, CA 95307 m <br /> D <br /> Schulte Road 209-230-09 67 ac Agricultural <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# g z <br /> In <br /> N <br /> OWNER NAME Sandeep Singh PHONE 209-513-0508 !A. <br /> OWNER ADDRESS P O Box 2509 CRV/STATE/ZIP Ceres CA 95307 <br /> CONTRACTOR Nor-Cal Pump and Well Drilling PHONE 530-674-5861 <br /> CONTRACTOR ADDRESS 1325 Barry Road Cm/STATEfZp Yuba City, CA 95993 <br /> SUBCONTRACTOR None PHONE P <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP C <br /> LICENSE X$C-57 VG61 D-09 I Other NUMBER 908591 EXPIRATIONDATE 1/31/2018 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section seses <br /> .� <br /> INTENDED USE DomestidPrivate rrigation/Agricultural)•Industrial I Water Quality Monitoring i Soil Sampling/Characterization � O <br /> Public Water System Q U <br /> If different from Owner: Water SyStem Name Confac ame or ne um er Q> CA1 <br /> C3- <br /> TYPE OF WORK New WeIIXX I ReplacementWell I Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells i Soil Boring(s) #of borings I Geotechnical #of bori ge 1= <br /> L Out-Of-Service Well L Out-Of-Service Well Renewal L Cross-Connection Repair a <br /> •New Pum L Pum Replacement -i Pum Repair L Raise Well CasingO Ct7 <br /> WELL CONSTRUCTION -X x --C; <br /> Drilling Method Mud Rotary I Air�otary I Auger I Cable Tool i I Push Point i Other Flooded Reverse Rotary � <br /> Proposed Well Depthv'40'8-- '3 kC5 Excavation 20" in diameter I Open Bottom I Gravel Pack/Gravel Size TBD in diameter � [�• r„w'• <br /> _ Conductor.Casing in diameter / Conductor Casing Depth ft <br /> 12 .250 inche <br /> Well Casing Diameter i Thicknes/GaugeIASTM Sched Steel U Plastic finless Steel Other <br /> i'sj U y ` 50 T 10.3 sack T <br /> Grout Seal Depth• - Neat Cement(94 lb bag/5-10 gal water) I(�Sand Ce ent sack mix/7 gal (er <br /> Bentonite 0%solids Other • C Q <br /> V, Grout Placement Method d Free Fall i Other � Retardant/Accelerator < �!� •� j <br /> PEDESTAL Installed By Driller et,Pump Contractor C Other -d C <br /> Concrete Pedestal_Dimensions:Width It Length ft Thick in �Christy Box _. Stove Pipe L LU <br /> CO <br /> PUMP - Submersible?Turbine - Other HIP Pump Set It 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 I <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 /> M}A(IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - TITLE Vice President DATE 2/15/2016 <br /> �s3" p <br /> fi <br /> Z W Q <br /> LU <br /> a05Z <br /> 7ZJ <br /> .;., W <br /> ZZ <br /> f � <br /> r-DEPARTMENT qSE ONLY S <br /> Application Accepted By E to I <br /> L "C) I Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS iit/bA L tv (p- ,k w Lllll <br /> b' -o t Lk b1 t( CkSll <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B Cash Remitted Service Request# <br /> LAJEHD 43-06 li` ry b O O L A) -S c- 4 <br /> L5v 6L�C �O��C• <br />