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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 /> JOB ADDRES1194 Linne Rd/Cross with Kasson CITY/ZIP0 <br /> 239-210-19 ��jj� D <br /> CROSS STREET APN PARCEL SIZE/ LAND U E APPLICATION# °oA <br /> OWNER NAME Rabb Family Propertis PHONE (209)914-1392 N <br /> OWNER ADDRESS 3828 Ambrosia Lane CITY/STATE/ZIP Modesto,Ca 95356 <br /> CONTRACTOR Building Solution&Drilling, Inc PHONE (925)785-2015 <br /> CONTRACTOR ADDRESS 3494 Camino Tassajara#203 CITYISTATE/ZIP Danville,Ca 94506 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE XC-57 C-61 D-09 Other NUMBER 1022423 EXPIRATION DATE 04/19 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Xlnigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK j(New Well I Replacement Well Well Alteration/Modification XOther reverse circulation <br /> Monitoring Wells) #of wells Soil Boring(s) Ifor borings Geotechnical a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> NewPump Purop Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary Air Rotary Auger Cable Tool Push Point X Other raversa 6rrtdatinn <br /> Proposed Well Depth !_0 ft Excavation 26 in diameter Open Bottom X Gravel Pack/Gravel Size -3/8 in diameter <br /> Conductor Casing " in diameter / Conductor Casing Depth N/A ft <br /> Well Casing Diameter 16 in Thickness/Gauge/ASTM Schad 0225 1 XSteel 1 Plastic Stainless Steel Other <br /> Grout Seal Depth ft570 f Neat Cement(94 Ib bag/5-10 gal water) X Sand Cement 11.5 sk sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fall Other Retardant/Accelerator(name) N/A <br /> PEDESTAL Installed By Driller XPump Contractor Other <br /> Concrete Pedestal Dimensions:Width R 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 COMPENS ION LAWS. � /I <br /> MINIM"Tr APjt4gE/tJOIT,LCE REQUIRED FO INSPECTIOYS-PLEASE CALL(209)953-7697 <br /> SIGNED 1 ll....C�.��„�«l<�///J/”""��LLLL TITLE I e h'� DATE I I(a t 7Zi <br /> f <br /> ECM��r <br /> EIVEA <br /> J RpNM COUNT), <br /> DE' MFNT <br /> �\ DEP RTMENT USE PNLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By YZ C 11 Date I WAIVER Received x/� <br /> Soil Boring Inspectio ey Date C nstructe Well Depth v ft <br /> COMMENTS w <br /> 1,76 <br /> PE $C Received Check#I Amoun Date Permit/ nice# Well ID# <br /> Codes Ifo By. Cash Remitted Service Re uest# <br /> a <br /> END 43-06 8/01/16 �5q 1 WELL/PUMP PERMIT <br />