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ki <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IYUIY-Rth UNUA5Lt YEKMIT I:ALL (-LU: <br />Joe ADDRESS 1206 E. March Lane <br />553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CROSS STREET West Lane ApN 104 16 004 <br />OWNER NAME DP&DK Investments, Inc. <br />OWNER ADDRESS 1206 E. March Lane <br />CONTRACTOR Professional Service Industries (PSI) <br />CONTRACTOR ADDRESS 4703 Tidewater Avenue, Suite B <br />SUBCONTRACTOR Woodward Drilling Co, Inc. <br />SUBCONTRACTOR ADDRESS 550 River Road <br />LICENSE X C-57 C-61 D-09 Other NUMBER <br />CITY/ZIP Stockton, CA <br />:CEL SIZE '73 Ac. LAND USE APPLICATION # <br />PHONE (51) 857-7816 <br />CITY/STATE/ZIP Stockton, CA <br />PHONE (510)434-9200 <br />CITY/STATE/ZIP Oakland, CA 94601 <br />PHONE (707)374-4300 <br />CITY/STATE/ZIP Rio Vista, CA 94571 <br />710079 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X 38.001357 y -121.2909 Township_ Rang¢ Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name ontact ame or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells Soil Boring(s) # or borings X Geotechnical 5 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair 4 to 15' <br />New Pump Pump Replacement Pump Repair Raise Well Casing 1 to 50 <br />WELL CONSTRUCTION <br />Drilling Method Mud Ro ry 1 Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth D ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickne /Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth t ft eat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Ther Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />at, MP 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 ANDACT WITH TH ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COM A L ,� <br />MI U NCE I�pTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 95 -76 7 <br />SIGNED TITLE PSI Project Geologist DATE 6 1 ILI 1 Ile <br />orF <br />6P <br />Application Accepted <br />Grout Inspection <br />Pump Inspection <br />Soil Boring Inspection <br />0 <br />m <br />m <br />N <br />REP41eivr <br />';Vle p <br />4U6 2 8 ?018 <br />JOAQUHRDEP�,, 7AL T Y <br />ARTINENT <br />TMENT USE N Y <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />Date <br />Area Employee ID#lli� <br />Date <br />SPECIAL Well Permit <br />Date <br />WAIVER Received <br />Date <br />Constructed Well Depth —_ — It <br />PE SC ReceivedgbjeclliiAmount Date <br />Codes Info By Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest# <br />EHD 4306 <br />4130/12 <br />WELL /PUMP PERMIT <br />0111 e <br />/r <br />Gi <br />