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1 <br /> c <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 2929 Wildflower Lane CITYIZIP Stockton 95212 y <br /> D <br /> CROSS STREET Holman Road APN 13004003 PARCEL SIZE 49 LAND USE APPLICATION# N/A °o <br /> A <br /> OWNERNAME STOCKTON UNIFIED SCHOOL DISTRICT PHONE 209-933-7000 N <br /> OWNER ADDRESS 701 N.MADISON STREET CITYISTATEIZIP STOCKTON.CA 95202 <br /> CONTRACTOR WALLACE-KUHL&ASSOCIATES PHONE 916-372-1434 <br /> CONTRACTOR ADDRESS 3050 INDUSTRIAL BLVD CITYISTATE/ZIP WEST SACRAMENTO,CA 95691 <br /> SUBCONTRACTOR V&W DRILLING. INC PHONE <br /> SUBCONTRACTOR ADDRESS 3806 DUCK CREEK DRIVE CITY/STATEIZIP STOCKTON,CA 95215 <br /> LICENSE X C-57 C-61 0-09 - Other NUMBER 720904 EXPIRATION DATE 4/30/2020 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(439 1) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestidPnvate _ Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characlenzation <br /> Public Water System <br /> If different I—Owner Water System Name Contac[Name or Phone Number <br /> TYPE OF WORK -New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) I bongs XGeolechnlcal 15 Kabmlgs <br /> Out-of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drllling Method Mud Rotary - Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 5-25 ft Excavation 6 in diameter Open Bottom Gravel Pack/Grave)Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 5-25 It X Neat 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 X Free Fall Other Retardant/Accelerator(name I <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 Turbine Other HP Pump Set It Standing Water Level 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 COMPENSATION LAWS. <br /> IyJNIM M HO R DVA�N.CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED I1 Ir^ u TITLE SENIOR ENGINEER DATE <br /> ■ <br /> RE <br /> JUL <br /> SAN JOA ... - L- I - I I I I I I - 1 1 ,$1 <br /> ENVIR <br /> HEALTH <br /> DI�Ej,P�A_9T M E N/T 7S E O N L Y <br /> Application Accepted By v V" Date` L 2201 Area Employee ID# 54 <br /> Grout Inspection By I I Date .. SPECIAL Well Permit <br /> Pump Inspection By Dale WAIVER Received <br /> Soil Boring Inspection By 1.1 Dale Constructed Well Depth ft <br /> COMMENTS <br /> ul <br /> PE SC Received Ctleck#1 Amount Permit/ <br /> Codes Info Bv Cash Remitted Date Se ice Re eat# Invoice# Well ID# <br /> �/tS fti <br /> G` 4J 1 <br /> END 4306 revved 4114115 WE'L,PUMP PERMIT <br />