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4 • <br />-44 <br />a <br />1 <br />U. <br />• <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA ZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />Joe ADss I-InlmAn onAd Ciry/Zie Stockton/95212 <br />NON-REFUNI*BLE PERMIT _ www.sigov.orofehd. EXPIRFS 1 YFAR ponm DATE ISSUED <br />r9 L3 <br /> <br />_PARCEL SIZETtiAgIND USE APPLICATION # CROSS STREET Holman Road & hendrix Drive APN 122-020-39 <br />KB Homes North Bay <br />OWNER NAME PHONE <br />1261 Prospect street I suite 9 Cry/sun/zip La 4olla I Califomia 192307 OWNER ADDRESS .... <br />Hillside Geotechnical Drilling PHONE 209-815-5440 CONTRACTOR <br /> <br />PO BOX 143 Tracy, CA, 95378 CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br /> Mid Pacific Engineering PHONE 916-767-8082 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 840 Embarcadero Drive. Suite .90 <br />LICENSE VC-57 0 C-61 C D-09 0 Other NUMBER <br />BILLING PARTY: 0 OWNER 0 CONTRACTOR B/SUBCONTRACTOFt/CONSULTANT <br />CITY/STATE/ZIP West Sacramento, CA, 95605 <br />800276 <br />EXPIRATION DATE 6130/2021 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />lirrownan iiRR <br />O Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 9/Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />0 New Well 0 Replacement Well 0 Well Alteration/ModlicAon 0 Other <br />..... . 0 Monitoring Well(s) IS of wells 9' Soil Boring(s) 4 of borings 0 Geotechnical a of borings <br />0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />ri New Pimp 0 Pump Replacement 11 Pump Recair fl Rake Well CANnn <br />WELL CONSTRUCTION. <br />Drilling Method 0 Mud Rotary 0 Air Rotary NI/Auger 0 Cable Tool 0 Push Point 0 Other <br />4.0 inches Proposed Well Depth 16 ft Excavation in diameter 0 Open Bottom <br />0 Conductor Casing in diameter 1 Conductor Casing Depth <br />Well Casing Diameter ___ in Thicknesspauge/ASTM Sched <br />Grout Seal Depth j--ft N/Neat Cement (94 lb bag/5-10 gal water) Steel <br />0 Bentonite (20% solids) 0 Other <br />grout Placement Method 0 Pumped 94ree Fall 0 Other 0 Retardant / Accelerator (name) <br />'EDESTA). Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODimensions: Width Length ft Thick 0 Christy Box C Stove Ploe <br />I P•u442- o Submersible° Turbine C Other HP Pumo 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 WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI 48,1HASUR A VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED TITLE C s 1-hide r DATE 4/2212021 <br />TwaE oc wosav <br />0 Gravel Pack/Gravel Size in diameter <br />ft <br />0 Plastic 0 Stainless Steel 0 Other <br />C Sand Cement Rack mix17 gal water <br />a. <br />Nam um EN mosinimmam sonu IIIMUNIMINIMEM M111111 <br />MIEN <br />I . <br />-_L —_L et! <br />DEPARTMENT USE ONLY <br />Application Accepted By aitO Ie. Date Area a kfZ kiLV'l Employee ID# <br />.17.1 SPECIAL Well Permit <br /> Date _ WAIVER Received <br />Date 5/ 2.1 Constructed Well Depth ft <br />Received 7 Checkal Amount <br />Cash . . . <br />&. • a 1E2aIrBeratiliiri. <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Permit/ Invoiced Well IDA <br />END 4346 fin 1120:19 <br />C&i242U24 o <br />WELL /PUMP PERMIT