Laserfiche WebLink
JOB ADDRESS 286 West Clover Road CiTY/ZiP Tracy, CA 95376 <br />CITY/STATE/ZIP Sacramento, CA 95814 OWNER ADDRESS 428 J Street, Suite 500 <br />Cm/STATE/ZIP Galt, CA 95632 1133 Blackhurst Drive CONTRACTOR ADDRESS <br />CITY/STATE/ZIP West Sacramento, CA 95605 840 Embarcadero Drive, Suite 20 SUBCONTRACTOR/CONSULTANT ADDRESS <br />OWNER CONTRACTOR JSUBCONTRACTOR/CONSULTANT BILLING PARTY: <br />Buthmann Ave 21-443-005 0.47 acres <br />CROSS STREET APN PARCEL SIZE LAND USE APPUCATION # <br /> <br />Jared Ouellette C/o Degenkolb Engineers (for Owner) 916-905-8461 OWNER NAME PHONE <br />CONTRACTOR V&W Drilling, Inc. <br />PHONE 209-981-7755 <br />Mid Pacific Engineering, Inc. (MPE) 916-927-7000 SUBCONTRACTOR/CONSULTANT PHONE <br />EXPIRATION DATE 1111/3° 4101` LICENSE /C-57 C-61 D-09 Other NUMBER 720904 <br />Retardant / Accelerator (name) Grout Placement Method Pumped Free Fall Other <br />ft Thick <br />PEDESTAL Other <br />ft Length Christy Box Stove Pipe <br />Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions: Width <br />PUMP HP Pump Set ft Standing Water Level ft Submersible Turbine Other <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 LAW <br />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />MPE Authonzed Agent (Consultant) 02-04-2021 TITLE DATE SIGNED <br />MINIMUM 4 HO <br />PAYMENT <br />ECEIVED <br />TB 0 4 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br />EALTH DEPARTMENT <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary <br />Proposed Well Depth 20 - 25 <br />Air Rotary V Auger Cable Tool Push Point Other <br />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 8 in Thicknesspauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 20 - 25 ft 0/Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack rnix17 gal water <br />Bentonite (20% solids) Other <br />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 />DOMESTIC WELL SAMPUNG: 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 />ii chnerent horn Owner Water System Name Contact Name or Phone Number SS31:1CIOV 311S New Well Replacement Well )Nell Alteration/Modification Other <br />Monitoring Well(s) # of wells /Soil Bonng(s) 3 a nt bonngs Geotechnical <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />TYPE OF WORK <br />H ot borings <br />DEPARTMENT U E ONLY <br /> <br />cApplication Accepted By 2--- el" Date .97 9 c2 i Area /r 1 c' . Ly Employee ID# As <br />1 .-1-- 4— ---,,* Grout Inspection By 4 -Date SPECIAL Well Permit <br /> <br />Pump Inspection By Date WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Receive <br />y <br />‘3;04211#16--- <br />Cast' 4 n- _ <br />Amount <br />Remitted Dl e Permit/ <br />Service Request # Invoice # Well ID# <br />-U 93 1 ID S 1 2,0 2-bo 470 )16.4 tal infosit (I) Sap <br />ft <br />DID .3-06 6/11/2019 WEL ir„mn RMI'