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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 /> N <br /> JOB ADDRESS 242 E.Miner Avenue clTv/zIP Stockton/95202 � <br /> D <br /> CROSS STREET N.Hunter Street APN 139-13-001 PARCEL SIZE 0.12 aC.LAND USE APPLICATION# A <br /> OWNER NAME Visionary Home Builders,CA dha VCOR LP-Contact:Justin Llata PHONE 209.466.6811 H <br /> OWNER ADDRESS 315 N.San Joaquin Street CITY/STATE/ZIP Stockton,CA 95202 <br /> CONTRACTOR V&W Drilling-Contact:Karli Stroing PHONE 209.981.7755 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITY/STATE/ZIP Galt,CA 95632 <br /> SUBCONTRACTO CONSULTANTCondorEarth-Contact:Ron SkaQQs,Principal Enl;ineer PHONE 209.532.0361,Ext.2211 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 188 Frank West Circle,Suite I CITY/STATE/ZIP Stockton,CA 95206 <br /> LICENSE X C-57 J C-61 D-09 C Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <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 n Water Quality Monitoring Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 1,Replacement Well Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells Soil Boring(s) fl of borings X Geotechnical I it of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal �i Cross-Connection Repair <br /> New Pum ❑Pump Replacement a Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary k Auger Cable Tool _;Push Point ❑ Other <br /> Proposed Well Depth 30 to 50 ft Excavation 4 1/2 in diameter Open Bottom [I Gravel Pack/Gravel Size in diameter <br /> -i Conductor Casing in diameter / Conductor Casing Depth It <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 Ib bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) I Other <br /> Grout Placement Method ❑Pumped Free Fall X Other Tremie i Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller Pump Contractor 7 Other <br /> D 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 V41TH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI HOU D aE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Coordinator DATE 04/28/2020 <br /> RFq yMF <br /> APR <br /> Jig <br /> ?0 <br /> R QU/N ?o <br /> Tjy�pgRTp�NrY <br /> MFNr <br /> �7 DEPARTMENT USE ONLY 7�jy <br /> Application Accepted By �—�`�L Date ZoaO Area s" hEmployee ID# <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 Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted sent C'qquest# <br /> y s0 y <br /> EH043-0fi 6/11 12019 �/ �� WELL(PUMP PERMIT <br />