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w <br /> A <br /> 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.sjgc,v.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS I O 1u IS 4 Holman Rd&Colonel Mark Taylor S CITY/ZIP Stockton.95212 m <br /> CROSS STREET Holman RdAPN 122-020-510-000 PARCEL SIZE 13.3 acresLAND USE APPLICATION# o <br /> 247217-acres z <br /> m <br /> OWNER NAME PI QH I I.0 PHONE �y,+ <br /> OWNER ADDRESS 3400 E EIGHT MILE RD STE A CITY/STATE/ZIP STOCKTON CA 95212 <br /> CONTRACTOR V&W Drilling PHONE 209-469-7700 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt,CA,95632 <br /> SUBCONTRACTOR/CONSULTANT Wallace-Kuhl&Associates PHONE 916-372-1434 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 3050 Industrial Blvd. CITY/STATE/ZIP West Sacramento,CA,95691 <br /> LICENSE X C-57 1 1 C-61 11 D-09 1_1 Other NUMBER 720904 EXPIRATION DATE 04/30/22 <br /> BILLING PARTY: X OWNER C CONTRACTOR 1.1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:11 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 1 Domestic/Private ❑Irrigation/Agricultural ❑ Industrial L Water Quality Monitoring L Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well I i Replacement Well i i Well Alteration/Modification i Other <br /> I Monitoring Wells) #of wells 11 Soil Boring(s) #of borings X Geotechnical 5 #of borings <br /> i Out-Of-Service Well a Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> i New Pump I Pump Replacement I 1 Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ,Mud Rotary I Air Rotary K Auger I Cable Tool 1 Push Point fi Other <br /> Proposed Well Depth 15 ft Excavation in diameter n Open Bottom I l Gravel Pack/Gravel Size in diameter <br /> -I Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 i Steel 1I Plastic L Stainless Steel a Other <br /> Grout Seal Depth 1 S ft X Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> 1 Bentonite(20%solids) 1-1 Other <br /> Grout Placement Method i Pumped x Free Fall X Other tremle if water encountered n Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller L1 Pump Contractor I Other <br /> i Concrete Pedestal 1 Dimensions:Width ft Length ft Thick in 1 Christy Box L Stove Pipe <br /> PUMP J Submersiblef jxrbine ()Ker X HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 AVE PREP D Ty APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI ES, ST AW5, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVVTHE OR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE S N LAWS <br /> MIN 8 HOU OTICE REQUIRED FOSPECTIONS-PLEASE CALL(209 953 7697 <br /> J. <br /> SIGNED TITLE A&I►I i AIV, DATE <br /> loop i V-0 <br /> I T. <br /> DEPARTMENT USE ONLY �i ART io <br /> Application Accepted By �� r" L l� Date 7/d91,203V Area 0 % Employee ID# <br /> Grout Inspection By ��� Data k ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Re uest# <br /> �i37d4106q <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />