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a, <br />Vy. <br />PE' <br />E - <br />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 ADDRESS �111�.. Q� <br />CITY/ZI-P Ca 95356 <br />CROSS STREET `�/ APN 239-210-19 <br />Tr �yyModesto <br />PARCEL SIZE / "LAND USE APPLICATION # <br />OWNER NAME — Robb_Family Properties <br />PHONE (209) 914-1392 <br />OWNER ADDRESS 3828 Ambrosia Lane <br />CITY/STATE/ZIP Modesto, Ca 95356 <br />CONTRACTOR One Source Drilling & Pumps <br />PHONE �(05),7AS-7D15 <br />CONTRACTOR ADDRESS 3494 Camino Tassajara # 227 <br />CITY/STATE/ZIP Danville, Ca 94506 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE X C-57 C-61 D-09 Other NUMBER 1002672 EXPIRATION DATE 04)2017 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township Range Section_ <br />INTENDED USE Domestic/Private Xirdgation/Agricultural Industrial <br />Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />Service Regi <br />If different from Owner: Water System Name <br />on ac ame or lone NumberlavrInIN <br />TYPE OF WORK X New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring # of borings s) Geotechnical ofborings�� <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Replacement Pum Repair <br />Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary A1j Rotary Auger Cable Tool <br />Push Point X Other or revers circulation TBD <br />Proposed Well Depth '4M "35A Excavation 26 in diameter <br />Open Bottom X Gravel Pack/Gravel Size 3/8 in diameter . <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched 0.250 <br />X Steel Plastic Stainless Steel Other <br />q Grout Seal Depth It l 510Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method X Pumped Free Fall Other <br />Retardant / Accelerator (name) 10.3 sk Sand Slurry <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length <br />ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP <br />Pump Set ft 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS.��// <br />MINIMUM 24 HOUR-ASia4NCaCn1C QUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE owner DATE <br />m <br />SIT <br />RED <br />EIVEC" <br />L 0 9 2015 <br />ENTAL HEALTH <br />DEPARTMENT USE ONLY v <br />Application Accepted By �' Y""�J�` <br />_ Date <br />r r <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />l� <br />Soil Boring Inspection qBjly <br />Dale <br />W? <br />COMMENTS _5,,6,A t .L+jp - <br />.tt��' �vw.t�Jl.ttir g�'` --��uYC <br />JI����►`�f'-.� <br />f�5 <br />PE SC raecei'ad Check#/ <br />I <br />Amount Date <br />Permit/ <br />Codes Info I By Cash <br />RemitteQ <br />Service Regi <br />A <br />Il / �/ji <br />15ROO7o <br />m <br />SIT <br />RED <br />EIVEC" <br />L 0 9 2015 <br />ENTAL HEALTH <br />EHD 43-06 tG�iQbl f f +'�, LL S Wt A%Y.PLILIXIA.v "tr 'rt -'T �( WELL /PUMP PERMIT <br />4/30/12 <br />4.0ytiltw l�`r 4„4'kwWr l5bt <br />Ln <br />Z uu <br />ZLU <br />l� <br />W? <br />000 <br />��.��,;� <br />Area Employee ID: ~ <br />..i <br />Q 5; <br />U> <br />SPECIAL Well Permit <br />C+ (� <br />? <br />z W <br />= WAIVER Received <br />to S <br />Constructed Well Depth ft <br />:al Indk d W -D <br />EHD 43-06 tG�iQbl f f +'�, LL S Wt A%Y.PLILIXIA.v "tr 'rt -'T �( WELL /PUMP PERMIT <br />4/30/12 <br />4.0ytiltw l�`r 4„4'kwWr l5bt <br />