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V <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />F14-KEFUNDABLE YEKMII WWW.S Ov.Of Ier10 CArIKCA T TtAK I-KUM UAIt IS,UtU <br />ADDRESS 1555 N Chrisman Rd CITY/ZIP Tracy 95304 <br />SS STREET Paradise Avenue APN 25002091 PARCEL SIZE 54.25 aCTAND USE APPLICATION # <br />IER NAME 1 IOl'O�i S M C+19r j�PHONE �J <br />IER ADDRESS 18c70 Vnze2 S� CITY/STATE/ZIP VP.YI �IPiT L D gaaoa <br />TRACTOR Kleinfelder PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/LP Stockton, CA 95206 <br />SUBCONTRACTOR/CONSULTANT VRW Drilling PHONE 209469-7700 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Dr CITY/STATE/ZlP Galt, CA 95632 <br />LICENSE X C-57 0 C-61 0 D-09 ❑ Other NUMBER 720904 EXPIRATION DATE 4/30/2022 <br />BILLING PARTY: D OWNER XCONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE D Domestic/Private 0 Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring X 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 ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(S) # of borings X Geotechnical 5 # of borings <br />0 Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method X Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool Push Point ❑ Other <br />Proposed Well Depth 50 ft Excavation 6 in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth S' ft X Neat Cement (941b bag/5-10 gal water) 0 Sand Cement sack m/x!1 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method 1K Pumped 0 Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimensions: Width it Length It Thick in 0 Christy Box D Stove Pipe <br />PUMP 0 Submersible[] Turbine ❑ Other HP Pump Set It 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 />DEPARTMENT USE ONLY <br />Application Accepted Byy Date 3 a3 aZ Area S "1 "rco� Employee ID# As <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection B ate Constructed Well Depth it <br />COMMENTS <br />U_1 <br />D <br />0 <br />°z <br />inw <br />pAY�pVE� <br />RECE <br />�Q 2021 <br />SAN JOAQUIN COUNTY <br />ENVIROF PARMENT►AENT <br />FAL <br />HEALTHD- <br />MMII/1i?7/I� <br />�.. <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />