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r <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 /> N <br /> JOB ADDRESS Stockton 1-5 Post Mile 25 to 32.7 CITY/ZIP Stockton/95204,95207,95219 m <br /> D <br /> 0 <br /> CROSS STREET West March Lane APN PARCEL SIZE LAND USE APPLICATION# <br /> m <br /> N <br /> OWNER NAME Caltrans Right of Way PHONE vi <br /> OWNER ADDRESS NA CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder PHONE 916-366-1701 <br /> CONTRACTOR ADDRESS 2882 Prospect Park Drive,Suite 200 CITY/STATE2IP Rancho Cordova,CA 95670 <br /> SUBCONTRACTOR Kleinfelder PHONE 916-366-1701 <br /> SUBCONTRACTOR ADDRESS 2882 Prospect Park Drive,Suite 200 CITY/STATE/ZIP Rancho Cordova,CA 95670 <br /> LICENSE V C-57 C-61 D-09 Other NUMBER 467252 EXPIRATION DATE 12/31/16 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural _ Industrial Water Quality Monitoring f Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water 6ystem Name Uontact Name or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) *ofbodngs ,r Geotechnical6 #ofbodngs <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 /> Drilling Method Mud Rotary Air Rotary Auger Ci ble Tool i Push Point i Other <br /> r � <br /> Proposed Well Depth"3� ft Excavation �in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad - Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 30 ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method Pumped Free Fall ❑r Other Trernie Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length ft Thick in Christy Box Stove Pipe <br /> Pu MP Submersible Turbine Other HP 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 OU DVA,INCE NOTICE <br /> �/REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 1µ111,c, f 1�rM,�(.� TITLE Geologist DATE 7/26/2016 <br /> CEIVEr <br /> 1;4 <br /> US" 2016 <br /> �/SERVICETH <br /> SA EURO E <br /> NEA)-TM D <br /> P RTMENOUE NLY <br /> ,/�� .^Application Accepte Date // Area Employee ID# tVGrout Insp tion By DatelO IJ SPECIAL Well Permit <br /> Pump Inspe y Date L: WAIVER Received <br /> Soil Boring In a tion By. D to Constructed Well Dep ft <br /> COMMENTS /� a O CJ �7 /.:J�-�' <br /> PE SC Received Che Amount PermiU TL <br /> Codes Info By ash Remitted Date Service Re uest# Invoice# Well ID# <br /> dZ-17- it� S32 3 o gib S-y J <br /> EHD 43-06 <br /> 4/30/12 WELL/PUMP PERMIT <br />