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ti <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />I;ALL [ZUVVbJ-/bUI FOR INSPECTIONS EAPIKtS l TEAR FROM UATE ISSUED <br />JOB ADDRESS 28301 S. Lammers Road _ <br />C yrb, Tracy / 95377 <br />_. Date _ _ <br />25105007 / <br />25106007 / 25336006 / 116 / <br />CROSS STREET S [.ammers Roes <br />- <br />APN <br />PARCEL SIZE LA ND USE APPLICATION # <br />John Paiu.er <br />Pump Inspection By <br />\ "'- <br />�L�IIi: <br />OWNER NAME <br />PHONE <br />OWNER ADDRESS - 888 San Clemente Shite 100 <br />�i wV <br />• t (' eRT/ TATE'/ZI tlewport Beach, CA 9 <br />CONTRACTOR E-NGEO Inc. <br />COMMENTS n zei <br />tet <br />PHONE 209-684-7611 <br />CONTRACTOR ADDRESS 17276 Go_den Valley Parkway <br />CRY/STATE/aP Lathrop / CA / 95330 <br />SUBCONTRACTOR Geo -Ex Subsurface Exploration <br />PHONE 916-799-819E <br />SUBCONTRACTOR ADDRESS 1110 Madera Dr. <br />CtTY/STATE(IJP Dixon, CA, 95620 <br />LICENSE Y, C-67 C-61 _ D-09 <br />Otner <br />NUMBER EXPIRATIONDATE 6/30;2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangs Section <br />WENDED USE DomesticiPnvate -- Irngation/Agricultiral . Induslna�. Water Quality Monitoring 1: Soil Sam plin giCharacterization <br />Public Water System <br />If diff— fm,, 0— vv.te y ern — a eme or ne14— <br />C PT '- <br />Monitonng Weil(s I—_—#of wells 7, Soil Boring(s) 1G Al of bonrgs Geotechrical #otbunms <br />Out -0f -Service Well _ Out-0fService Well Renewal - Cross -Connection Repav <br />Drilling Method Mud Rotary Air Rotary x Auger Cable Tool Push Point Other <br />Proposed Well Depth_ 2c-60 ft Excavation 6 in diameter _ Open Bottom _ Gravel Pack/Gravel Size in d,.ameter <br />Conductor Casing In diameter I Conductor Casing Depth It <br />Well Casing Diameter _ In ThicknessiGaugefASTM Schell - Steel - Plastic Stainless Steel - Other <br />Grout Seal Depth 20-60 ft x Neat Cement (94 lb bags -10 gal Water) Sand Cement sack mix/7 gal water <br />- Bentonite(20% solids) Other <br />Grout Placement Method _. Pumped Free Fall x Other -. Retardant / Accelerator (name) <br />PEDESTAL Installed By . Driller Pump Contracto, Other <br />Concrete Pedestal Dimensions: Width ft Lergtn ft Thick In Christy Box Stove Pipe <br />PUMP Submersible-- Turbine Other_ _ HP Pump Set_ ft Standing Water Leve _ <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. 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 />MINIMUM 24 HOUR E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED..... -. �'--i .1 � TITLE r," <br />E-f,T'r•.ear DATE <br />_Lh <br />ig <br />PE SC Received <br />Codes Info <br />B14 <br />PA TMENT U E N Y <br />Amount Data PermlU Invoice# WeI11DA <br />Remitted Service Request <br />Application Accepted By <br />_. Date _ _ <br />Area- Employee ID#/ <br />_ - <br />Grout Inspection By <br />Date <br />�SPECIAL eII Permit <br />Pump Inspection By <br />_ ._ L _ Date <br />_ WAIVER Received <br />Soil Boring Inspection By <br />DD,atte� <br />/ Cons cted Well Depth <br />ft <br />COMMENTS n zei <br />� � <br />i� Qrl I.a M1 - �ildF'e=-=K C l (1!O <br />4 it) _._ ..-_-. <br />PE SC Received <br />Codes Info <br />B14 <br />CheclaW <br />Cash <br />Amount Data PermlU Invoice# WeI11DA <br />Remitted Service Request <br />'M <br />E- 13-ce <br />1.012 <br />Cf -1� g 113 <br />76` 47S7k <br />WELL /PUMP PERMIT <br />