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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 />I�LON-REFUNDABLE(.RER(MM1T �__ ` www.sigov.org/ehd. EXPIR C i YPAR cRnm DATE ISSUED <br />JOB ADORES$ 3(JG• Ve?ner CITYIZIP SIoCkt0n195212 <br />CROSS STREET Holman Road & hendrix Drive APN 122-02040 PARCELSIZfiQ41.T#9LAND USE APPLICATION # <br />KB HOmeS North Bay <br />OWNER NAME PHONE <br />OWNER ADDRESS 1261 Prospect street I suite 9 CITYISTATEIZIP La 4011a I California 192307 <br />CONTRACTOR side Geotechnical Drilling <br />PHONE 209-815-5440 <br />CONTRACTOR ADDRESS PO BOX 143 CITY/STATE ZIP Tracy, CA, 95378 <br />5UBCONTRACTORICONSULTANT Mid Pacific Engineering_ PHONE 916-767-8082 <br />ICTORICONSULTANTADORESS R40 FmharcaderD Drive CUlte 20 CITVISTATEIZIP West Sacramento, CA, 95605 <br />&57 0 C -fit C D-09 0 Other.--// NUMBER 800276 EXPIRATION DATE 613012021 <br />N <br />3TY: 7 OWNER 0 CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ❑General <br />Bacteria (4391) D <br />D Arsenic <br />IureunFn i tcE. 0 <br />Domestic/Private 0 <br />Irrigation/Agricultural D Industrial ❑Water Quality <br />Monitoring '4�$0ll Sampling/Characterization <br />0 <br />Public Water System <br />_ <br />I <br />If different from Owner: <br />Water System Name <br />Contact Name or Phone Number <br />T4N& nv Wnnv 0 <br />New Well 0 Replacement Well 0 Well Alteration/Modification <br />0 Other <br />0 <br />Monitoring Well(s) <br />.# of wells 9Soil Boring(s) ? #or <br />borings 0 Geotechnical of borings <br />0 <br />Out -Of -Service Well <br />C Out-Ot-Service Well Renewal <br />0 Cross -Connection Repair <br />WELL -CONSTRUCTION_ <br />Drilling Method 0 Mud Rotary 0 Air Rotary Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth 15 a Excavation 4.0 inches in diameter 0 Open Bottom <br />0 Conductor Casing in diameter f Conductor Casing Depth <br />0 Gravel Pack/Gravel Size in diameter <br />Well Casing Diameter _ in Thickness/ augelASTM Sched C Steel D Plastic D Stainless Steel D Other i <br />Grout Seal Depth 15 ft Neat Cement (941b bag/5-10 gal water) C Sand Cement pack mix/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />EDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br />0 Concrete Pedestal ❑Dimensions: Width —ft Length ft Thick �._ -in 0 Christy Box C Stove Pipe <br />P31me_ n SubmersibleD Turbine D Other HP Pump Set —. -- ----ft Standing Water Level._ ft I <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 />MINII�JI�(I 48- HQ`UR A� CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED , -`(,y TITLE r ' S7 ldw DATE 412212021 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date a <br />Grout Inspection By _ _ Date <br />Pump Inspection By 10, <br />,,_ Date <br />Soil Boring Inspection By Date "Z7 _ <br />COMMENTS <br />PE SC Received 1 Check#1 i Amount ate Permitl <br />Info B I Cash I <br />qarvira <br />Ul <br />I <br />EH043-06 6/1112019 <br />I2�f Z Lq t5o <br />Areae � �n Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />Invoice # <br />Well ID# <br />WELL/PUMP PERId1T <br />ti�UNN <br />