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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 /> Ul <br /> JOB ADDRESS 18243 State Route 26 CITY2IP Linden/95236 ADD <br /> CROSS STREET Northeast of Duncan Rd. APN 0 Id 003 Ir PARCEL SIZE 050 LAND USE APPLICATION <br /> m <br /> OWNER NAME Linden County Water District-Contact:Mark Ospital Cell:209.810.5807 PHONE 209.754.1824 y <br /> OWNER ADDRESS 18243 State Route 26 CITY/STATEMP Linden,CA 95236 <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITYISTATE21P Galt,CA 95632 <br /> SUBCONTRACTORICONSULTANT Condor Earth-PM:Chad Borean Cell:209.601.1430 PHONE 209.234.0518 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 188 Frank West Circle,Suite I CITYISTATE/ZIP Stockton,CA 95206 <br /> LICENSE XC-57 C-61 0-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT <br /> DOMESTIC 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 different from Owtec Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #of borings XGeotechnical 2 #ofborings <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 50 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 Other Tremie 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 It Standing Water Level It <br /> 1 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 /> M �j <br /> I 1 HOU REQUIRED <br /> REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 10/03/20 <br /> AAFNTD <br /> h Cm <br /> 20 <br /> NTY <br /> AL <br /> ENT <br /> DEPARTMENT USE ONLY DA <br /> Application Accepted By Lfc—��L� Date /0 Ov-.10.10 Area q� Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date `b "L `ZP�LL)Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount DatePermit/ Invoice# Well ID# <br /> Codes Info a h Remitted Service R "est# <br /> 7a o S <br /> EHD 43.06 6/11/2019 WELL/PUMP PERMIT <br /> 1 <br />