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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 /> Lo <br /> JOB ADDRESS 1739 Piper Place CITY/ZIP Tracy,95304D <br /> CROSS STREET Koster Rd. APN 255-310-340 PARCEL SIZE 1.55 acrgAND USE APPLICATION# O <br /> A <br /> In <br /> OWNER NAME Manuel Rosas PHONE 209-275-9308 <br /> OWNER ADDRESS 2384 Clemente Ln. Cm/STATE/7JP Tracy,CA 95377 <br /> CONTRACTOR Diamond Crane Company,Inc. PHONE 530-957-8101 <br /> CONTRACTOR ADDRESS P.O.Box 1613 CITY/STATErMp Diamond Springs,CA,95619 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIYISTATE/ZIP J <br /> LICENSE C-57 C-61 D-09 X Other—A NUMBER 714925 EXPIRATION DATE i o T) <br /> BILLING PARTY: X OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE x Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact 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) If of borings Geotechnical a 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 Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation 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 It 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 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller X Pump Contractor XOther <br /> X Concrete Pedestal Dimensions:Width R Length ft Thick 4 in Christy Box Stove Pipe <br /> PUMP Submersible Turbine x Other Force Pump HP 12 HD Pump Set ft Standing Water Level 36 It <br /> 1 HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Manuel Rosas TITLE Owner DATE 10/16/20 <br /> Plipe P ac <br /> R A yMF <br /> stIse <br /> o e�1 er Pl ce OQ�'N COUI� <br /> _DEPARTMENT USE ONLY <br /> Application Accepted By Date 16401'40,20 Areash Employee ID# F f <br /> Grout Inspection ByDate SPECIAL Well Permit <br /> Pump Inspection By f c&y lc i LS 41tj Date�� (tt ( WAIVER Received <br /> Soil Boring In ection y Date Constructed Well Depth <br /> COMMENTS PUMP <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re ue t# <br /> DSI <br /> EHD43-06 611112019 /ff2- —7 7 WELL 1PUMP PERMIT <br />