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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/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> Joe ADDRESS 255 W.Legacf, Dri,e CITYIZIP Mountain I louse.CA/95 391 <br /> D <br /> CROSS STREET Mercado Stre'e't APN 254-230-03 PARCEL SIZE 1 18 LAND USE APPLICATION# S <br /> OWNER NAME Marini Vunti and/or Chandra Strap PHONE 510.8.17.0805 a <br /> OWNER ADDRESS 800 1 lenlo'Court CITY/STATEIZIP San Ranion,CA 9.1583 ('u <br /> s <br /> CONTRACTOR V&11'Drilling-Contact: Karli Stroing PHONE 209,98 1 7755 y <br /> CONTRACTOR ADDRESS 1 133 131ackhurst Drive CITYISTATE/ZIP Cialt.CA 91632 <br /> f1r <br /> L' <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 Othef NUMBER 720901 ExPIRATION DATE 0.4130/2020 t; <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If ddrerent from owner Water System Name Contact Name or Phone Number <br /> f <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) •or bonny X Geotechnical 4 0 or bonngs > <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 L,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 PacklGravel Size in diameter <br /> r-Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth full depth M X Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mtxf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tret111e Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width tt Length It 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 TW71ECIIJIIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 03/11/20 <br /> J <br /> I IN <br /> MENT <br /> IVECI <br /> 2 2021 <br /> IN COUN i Y <br /> H MENTAL <br /> ARTMEi47- <br /> DEPARTMENT USE ONLY I <br /> Application Accepted By `! L--- Dale S �L Z v�J Area �' Employee ID# <<'/G�/tA,/ <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 <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> is !so <br /> EHCA306 6'112019 WEA_ IMP PERMIT <br />