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WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON VENUE - STOCKTON CA 95205 -6232 (209) 468 -3420 <br /> NON -REFUNDABLE PERMIT WwW. S ov. or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 717 W . Atherton Drive C /ZIP Manteca / 95337 m <br /> ^� D <br /> CROSS STREET Lakeside Avenue APN � PARCEL IZE 0 -' LAND USE APPLICATION # A <br /> OWNER NAME Valencia Place Apartments, LLC - Contact: Albert Boyce PHONE 209 . 234.4014 <br /> OWNER ADDRESS P . O . BOX 1870 CITY/STATE/ZIP Manteca, CA 95336 <br /> J <br /> CONTRACTOR V & W Drilling - Contact: Karli Stroing PHONE 209 . 469 . 7700 <br /> CONTRACTOR ADDRESS 1 133 Blackliurst Drive CITY/STATE/ZIP Galt, CA 95632 <br /> COD <br /> SUBCONTRACTOR/CONSULTANT Condor Earth - Contact: Ron Skaggs , Princi 1 Engineer, CA GE2295 PHONE 209 . 938 . 1040 0 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 188 Frank West Circle Suite l CITY/STATE/ZIP Stockton , CA 95206 d <br /> 720904 EXPIRATION DATE 04/30/2022 < <br /> LICENSE X C-57 C-61 D-09 Other NUMBER `D <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> CDC <br /> DOMESTIC WELL SAMPLING : General Mineral/Coliform Bacteria 4391 ) Dibromochloropropane (4392 ) Arsenic (4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural l <br /> ustrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water Sy em Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well ell Alteration/Modification Other <br /> Monitoring Well (s) # of wells Soil Boring (s) # of borings X Geotechnical 1 # of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary X uger Cable Tool Push Point Other <br /> Proposed Well Depth 20 ft Excava on 4. 5 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing i iameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/ auge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth full depth ft a( eat Cement (94 lb bag/5- 10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite (20% solids) Other <br /> Grout Placement Method Pumped F ee Fall X Other Tremie 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 /> PUMP Submersible Tu ine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HA PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANC STATE LAWS, AND RULES AND REGULATIONS , I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS . <br /> MINI R 6 UZOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209 ) 953 -7697 <br /> SIGNED TITLE Project Coordinator DATE 05/03 /21 <br /> AIN <br /> I it AAA <br /> Aq <br /> ki <br /> Ark q& N <br /> A <br /> � <br /> QUA FpFMNo <br /> 1A L <br /> q ,QTM�NT y <br /> DEPARTMENT USE ONLY <br /> Application Accepted Accepted By � Date ' Area / , 0,4er') Employee ID# AG. <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> Z Zb <br /> PE SC Received Check#/ Amount �Da a Permit/ Invoice # Well ID# <br /> Codes Info Cash Remitted Service R uest # <br /> YM �0 ILI 2 <br /> EHD 43-06 6/11 /2019 �T a4g3D '50 WELL /PUMP PERMIT <br />