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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 P VY <br /> IT WW1M.S oV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 4028 Undine Road CITY/ZIP Stockton 95206 m <br /> CROSS STREET S Roberts Road APN 191-070-170 PARCEL SIZE 106.88 LAND USE APPLICATION# O <br /> x <br /> OWNER NAME Olivera Family LTD.PTP PHONE rn <br /> OWNER ADDRESS 3315 Sierra Road CITY/STATEZP San Jose,Ca 95132 <br /> CONTRACTOR V&W Drilling Inc. PHONE 209-369-9600 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt/CA/95632 <br /> SUBCONTRACTOR/CONSULTANT Mid Pacific Enginering Inc. PHONE 916-662-0909 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive CITY/STATEZPW.Sacramento/CA/95605 <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Conlad Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells >(Soil Boring(s) It a of b0nnas X Geotechnical 1 #or borings <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 )e Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 50 ft Excavation 8„ 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 Repth 50 ft X Neat Cement(941b 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 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 <br /> it <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 AC WITH THE CALIF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO S ON LAW <br /> 48 HOU NC NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNS TITLE SZpC-G Ct4e,,kleE& DATE ,0123 I2010 <br /> IVIENT <br /> it EIVED <br /> 2 3 2020 <br /> SAIP UIN COUNTY <br /> ONMENTAL <br /> PAI DEPARTMENT <br /> DEPA TMENT U E ONL� Y 7 <br /> Application Accepted By / JT-ADate zo Area—> Ay Employee ID# <br /> Grout Inspection By(7 Fflto SPECIAL Well Permit <br /> Pump Inspection By Date / /,/�/'��/)� WAIVER Received <br /> Soil Boring Inspection By Date�V Constructed Well Depth ft <br /> COMMENTS1 - <br /> PE SC ReceivedAmount ate Permit/ Invoice# Well ID# <br /> Codes Info a Remitted Service Request# <br /> EHD 43-06 611120/9 WELL/PUMP PERMIT <br />