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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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 22 E.9th Street +`� /I r�^] CITy/7jp Tracy,CA 95376 byy <br /> CROSS STREET N.Central Avenue APN a 3SI b 10c� PARCEL SIZE '()7 LAND USE APPLICATION# o <br /> A <br /> m <br /> OWNER NAME Hung(Kevin)VV PHONE 408 460 2325 y <br /> OWNER ADDRESS 617 herr$ 91t)SSJY�'1 L N e CITY/STATE/ZIP Tracy,CA 9537b'7 N <br /> N <br /> CONTRACTOR V&W Drilling-Contact:Karli ['Ding PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1 133 Blackhurst Drive Cm/STATE/LP Galt,CA 95632 '- <br /> C/� <br /> SUBCONTRACTOR/CONSULTANT Condor Earth-Contact:Chad Borean,Project Manager PHONE 209.601.1430(Cell) <br /> SUSCONTRACTOR/CONSULTANr ADDRESS 188 Frank West Circle,Suite I CITY/STATE/ZP Stockton,CA 95206 <br /> d <br /> LICENSE X C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE 04/30/2022 <br /> (7 <br /> BILLING PARTY: OWNER CONTRACTOR X SUBCONTRACTORICONSULTANT a <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 O—er: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings X Geotechnical 2 #of 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 Mud Rotary Air Rotary XAuger Cable Tool Push Point Other <br /> Proposed Well Depth to 20 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 Sched 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 X Other Tremie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft 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 /> MINI OUR ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 01/08/2022 <br /> r <br /> T or <br /> NT <br /> ED <br /> 2021 <br /> X4 4C M 4E ouNrtr <br /> TAL <br /> TMENT <br /> J (DEPARTMENT USE ONLY /� <br /> Application Accepted By G �`' Date / / Area 5 IGS Employee ID# A5 <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 Receive# c Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted S ce Re ue <br /> u3�a so 1 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />