Laserfiche WebLink
, ♦r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />17VIV-Rtt'UNUAt7Lt rtKMl I www.slyov.oryfenU <br />CArIRCO "1 TtAK FKUM UAIt IJJUtU <br />JOB ADDRESS 25212 South Schulte Road <br />CITY/ZIP <br />Tracy 95377 <br />CROSS STREET Patterson Pass Road APN 20944036 <br />PARCEL SIZE 11.25 <br />LAND USE APPLICATION # <br />OWNER NAME CLPF - Patterson Pass 8, L.P. c/o JLL <br />PHONE 916-447-6300 <br />OWNER ADDRESS 3255 W. March Lane, Suite 105A <br />CITY/STATE/ZIP <br />Stockton, California 95219 <br />CONTRACTOR Intertek PSI <br />PHONE 510-434-9200 <br />CONTRACTOR ADDRESS 4703 Tidewater Avenue Suite B <br />CITY/STATEIZIP <br />Oakland, California 94601 <br />SUBCONTRACTOR/CONSULTANT V&W Drilling, Inc. <br />PHONE 209469-7700 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Drive <br />CITY/STATEIZIP <br />Galt, California 95632 <br />LICENSE X C-57 ❑ C-61 ❑ D-09 Ll Other <br />NUMBER 720904 <br />EXPIRATION DATE 04/30/2022 <br />BILLING PARTY: I1 OWNER ❑ CONTRACTOR <br />❑ SUBCONTRACTOR/CONSULTANT <br />DoMEsTlc WELL SAMPLING: []General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N Soil Sampling/Characterization <br />❑ Public Water System <br />If o§fferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) of wells ❑ Soil Boring(s) #of borings K Geotechnical 3 #of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 25 ft Excavation 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 25 ft X Neat Cement (94 /b bag/5-10 gat water) ❑ Sand Cement sack mW7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped N Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set It Standing Water Level It <br />1 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. 1 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �ft-ec TITLE DATE <br />fA <br />D <br />0 <br />mm <br />N <br />N <br />P TMENT U E__011NLY <br />Application Accepted By r Date ®� ,'r(.1-;�'/ Area / '7 Employee ID#,4��� <br />Grout Inspection By ate SPECIAL Well Permit <br />Pump Inspection By Date / f WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />WE Ell I WIT RM M <br />EHD43-06 611112019 ij /I I 1 ,�i7 ff/6— WELL/ PUMP PERMIT <br />ft <br />