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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 /> NON-REFUNDABLE PERMIT wWW.S Ov.cr /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> _N <br /> JOB ADDRESS 31228roDkside Road CITY/7JP StOCkton 195219 <br /> CROSS STREET west March lane APN 118-060-17 PARCELSIZE�(1'� LAND USE APPLICATION# <br /> Lincoln unified School District 209-953.8700 <br /> OWNER NAME PHONE <br /> OWNER ADDRESS 2010 West Swain Road I CITYISTATEIZIP Stockton I CA 195207 <br /> CONTRACTOR v&W Drilling PHONE 209-369-9600 <br /> CONTRACTOR ADDRESS 1133 Blackhurst Drive CITYISTATE171P Gait ICA 195632 <br /> SUBCONTRACTORICONSULTANT Mid Pacific Engineering PHONE 916-767-8082 <br /> SUBCONTRACTORICONSULTANT ADDRESS 640 Embarcadero Drive I Suite 20 CITYISTATE/LP west Sacramento I CaS3605 <br /> LICENSE VC-57 0 C-61 C D-09 0 Other NUMBER 720904 EXPIRATION DATE 4130/2022 <br /> BILLING PARTY: 7 OWNER 0 CONTRACTOR a SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Z Irrigation/Agricultural 0 Industrial 0 Water Oualiry Monitoring Z Soil Sampling/Characterization <br /> 0 Public Water System <br /> I If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Well(s) #of wells rY Soil Boring(s) 1 a of bodngs 0 Geotechnical a of borings <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> 0 New Pump 0 Pump Reblacemenl 0 Pump Recair 0 Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary S Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth 40 It Excavation 8 in diameter 0 Open Bottom 0 Gravel PacVJGravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesslGauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seat Depth4IN It *Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method-0 Pumped 0 Free Fall (d'Other tremie 0 Retardant I Accelerator(name) <br /> E ETA Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal❑Dimensions:Width^ft Length It Thick in 0 Christy Box C Stove Pipe <br /> PUMP 0 Submersible❑Turbine 0 Other HP Pump Set ft Standing Water Levei It <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 COMPENSATI N LA S. <br /> MINI O ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)c9953-7(,697f <br /> SIGNED TITLE F IA,ar DATE <br /> I I <br /> Fi <br /> r4n, <br /> &iAl <br /> I I 1 <br /> - I I <br /> qQ� ��P <br /> CO <br /> MA, <br /> F <br /> DEPARTMENT USEONLY 1 <br /> Application Accepted By4 Area3 S � Employee ID# � <br /> Grout Inspection By� � �4 Date I_l SPECIAL Well Permit <br /> Pump Inspection By _ __ Date, _ E WAIVER Received <br /> Soil Boring Inspection By_ __ Date Constructed Well Depth ft <br /> COMMENTS __ <br /> PE Sc Received Check#I Amount Date Permit/ Invoice Wa111D# <br /> j]Codes <br /> Info _ Cash Remitted Service R uest# <br /> EMD 47-05 6111/2019 � � WELL/PUMP PERMIT <br /> I <br />