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vtr aet, <br />rt W A <br />DEPARTMENT USE ONLY <br /> Date Application Accepted By <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection s <br />COMMENTS 67 <br />EHD 43-08 6/110019 WELL /PUMP PERMIT <br />Kleinfelder CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT "W Drilling <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Dr <br />PHONE 209-469-7700 <br />crryisTATE2p Galt, CA 95632 <br />XCONTRACTOR C SUBCONTRACTOR/CONSULTANT BIUJNG PARTY: E OWNER <br />Water System Name Contact Name or Phone Number <br />INTENDED USE 0 Domestic/Private E lrngation/Agricultural El Industrial G Water Quality Monitoring X Soil Sampling/Characterization <br />0 Public Water System <br />It different horn Owner: <br />sack mix/7 gal water <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary I Air Rotary X Auger I. Cable Tool I Push Point I Other <br />Proposed Well Depth 50 ft Excavation 6 in diameter 7 Open Bottom C Gravel Pack/Gravel Size in diameter <br /> <br />Ei Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel Plastic 0 Stainless Steel C Other <br />Grout Seal Depth ft X Neat Cement (94 lb bag/5-10 gal water) 7 Sand Cement <br />Bentonite (20% solids) Li Other <br />Grout Placement Method X Pumped = Free Fall C Other E. Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller 7 Pump Contractor <br />F..: Concrete Pedestal IlDimensions: Width ft Thick <br />Other <br />ft Length Christy Box 1 Stove Pipe <br />Pump Set ft Standing Water Level HP ft PUMP 7 Submersible: Turbine .. Other <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 EAST HAZELTON AVENUE - STocwroN CA 95205-6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED :SS9NOCIV DomEsTic WELL SAMPUNG: ' General Mineral/Coliform Bacteria (4391) U Dibromochloropropane (4392) C Arsenic (4393) <br />TYPE OF WORK 0 New Well E Replacement Well [7 Well Alteration/Modification E Other <br />0 Monitoring Well(s) # of wells C Soil Boring(s) ot Ocdngs X Geotechnical Rot borings <br />0 Out-Of-Service Well _. Out Of-Service Well Renewal ' . Cross-Connection Repair <br />0 New Pump E Pump Replacement E Pump Repair I Raise Well Casing <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 />NI M 48 1-TOU ADVANCE NOTICE REQUIRED FO INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE ( 17, eet, C)f-17-- DATE 1.--7 3-71 SIGNED <br />7 <br />(7?6, <br />6 otiv1 /4 41.1 se. <br />h. <br />,d1101.— <br />Nvroi <br />JOB ADDRESS 1555 N Chrisman Rd <br />d Paraise Avenue CROSS STREET ApN 25002091 <br />OWNER NAME P101'04-I Tr-e1C7 <br />OWNER ADDRESS FDO 62e€ S4- <br />Coy/Zip Tracy 95304 <br />PARCEL SIZE 54-25 acrEitixo USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP L:), oa <br />PHONE 209-948-1345 <br />6 1- <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 Crry/STATE/Zip Stockton, CA 95206 <br />LICENSE X C-57 L. C-61 _ D-09 Other NUMBER 720504 EXPIRATION DATE 4/30/2022 <br />Date <br />Area ---- /1-f-04 Y Employee ID# <br />L SPECIAL Well Permit <br />T WAIVER Received <br />Constructed Well Depth <br /> pAyigiENT <br /> RECEIVE° <br /> iy1A1 23 2°21 <br />t s p voiAR.Qou,tsiEcRN°T-rumANELT; <br />HEALTH D-. <br />PE <br />Codes <br />SC <br />Info <br />Received <br />y i <br />chaelW <br />Cast <br />Amount <br />2-Remitted Date Permit/ Invoice # Well ID# <br />L572 )(D. ( <br />Ati <br />J 2,1-92.3P t 130-1 37Z12-1 <br />OnalurstA ,......2 <br />3-4