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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> w <br /> Jon ADDRESS 4600 E. Freemont Street Cm/ZIP Stockton 95215 m <br /> D <br /> CROSS STREET E. Freemont Street APN 14331006 PARCEL SIZE 43 LAND USE APPLICATION# NIA <br /> 0 <br /> 9 <br /> m <br /> OWNER NAME STOCKTON UNIFIED SCHOOL DISTRICT PHONE 209-933-7000 N <br /> OWNER ADDRESS 701 N. MADISON STREET CITYISTATE/ZIP STOCKTON,CA 95202 ..� <br /> CONTRACTOR WALLACE-KUHL&ASSOCIATES PHONE 916-372-1434 <br /> CONTRACTOR ADDRESS 3050 INDUSTRIAL BLVD CITYISTATFJZIP WEST SACRAMENTO,CA 95691 <br /> SUBCONTRACTOR V&W DRILLING INC PHONE <br /> SUBCONTRACTORADDRESS 3806 DUCK CREEK DRIVE CITY/STATE/ZIP STOCKTON,CA 95215 1� <br /> LICENSE X C-57 C-61 - D-09 Other NUMBER 720904 EXPIRATION DATE 4)30)2020 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitenng X Soil SamplingiCharaclenzation <br /> Public Water System y <br /> If ddterent born owne.. Water System Name Contact Name w Phoria Number \ <br /> TYPE OF WORK New Well - Replacement Well Well AfteralionlModification Other <br /> 61ONtoring Wells) #of wells Soil Boring(s) 4 ofbonrgs X Geolechnical 15 Notborings ..y.._ <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 Meth CONSTRUCTION <br /> Drilling <br /> Method _ Mud Rotary - Air Rotary }(Auger _ Cable Tool Push Point Other <br /> Proposed Well Depth 5-25 ft Excavation 6 in diameter Open Bottom ..Gravel Pack/Gravel 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 4 X Neat Cement(94 Ib bag'5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bertonite(20%solids) - Other <br /> Grout Placement Method Pumped X Free Fall Other Retardant!Accet rater(ria el <br /> fk'PEDESTAL Installed By Driller PumpitoNtractor Other <br /> _ Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> au—.P Submersible Turbine Other HP Pump Set it Standing Water Level h <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 COMPENSS�A�TIIO�N�LAWS. <br /> M IMU)jJ Mvey`"SUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED !I I"/_ ..T1/1 1J. � Mr TITLE SENIOR ENGINEER DATE �011r X)6j <br /> ( <br /> I <br /> o> � <br /> y�F,o�F,j GCS <br /> FNr <br /> DEPARTMENT USE NLY <br /> Application Accepted By ✓ Date Z(,' Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Baring Ins tion By Date I Constructed Well Depth ft <br /> COMMENTS r v I <br /> PE SC Received Check#/ Amount Date Permit/ Invoke M Wall tD# <br /> Codes Info Cash R Orville Service Re nest# <br /> I 1 L ) 7-3 <br /> 0 Z`f E <br /> eHD 4i+to 11,10 a/14118 WELL/PUMP PERMIT <br />