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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 />Joe ADDRESS 3201 N Bacon Island Road CrrY/7jP Stockton, California <br />CROSS STREET. Bacon Island Road APN 129-05-026 y� PARCEL SIZE LAtIo USE APPLICATION <br />17 <br />OWNER NAME Delta Wetlands Properties M e } 71I (,.J� b 15j+r(L�-S <br />� !u.,AlO�l NE y�) <br />OWNER ADDRESS 1660 Olympic Blvd, Suite 350 Pe &X 53 CITY/STATEgJ Creek,`L�a I int <br />CONTRACTOR Gregg Drilling and Testing PHONE 925-313-5800 <br />CONTRACTOR ADDRESS 950 Howe Road CITY/STATE(Lp Martinez, California 94553 <br />SUBCONTRACTOR Hultgren - Tiflis Engineers PHONE 925.885.8300 <br />SUBCONTRACTOR ADDRESS 4085 Nelson Avenue, Suite A CITY/STATEIZIP Concord, California 94520 <br />LICENSE v C-57 D C-61 O D-09 0 Other NUMBER 485165 EXPIRATION DATE 0113112020 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) , Arsenic (4393) <br />INTENDED USE 0 Domestic/Privale 0 Irrigation/Agricultural H Industrial f i Water Quality Monitoring + Soil Sampling/Characterization <br />D Public Water System <br />If different horn Omer: WaterSystemNam Contac) Nam or Phone Number <br />TYPE OF WORK D New Well 0 Replacement Well 0 Welt Alteration/Modification 0 Other <br />0 Monitoring Wells) # of wells D Soil Bofing(s) # of borings d Geotechnical 5 # of borings <br />D Out -Of -Service Well LI Out -Of -Service Well Renewal D Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary D Air Rotary n Auger D Cable Tool rl Push Point i Other H0110 -Stem <br />Proposed Well Depth Approx 20 ft Excavation in diameter 0 Open Bottom D Gravel Pack/Gravel Size In diameter <br />D Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter 6 in Thickness/Gauge/ASTM Schad D Steel D Plastic D Stainless Steel U Other <br />Grout Seal Depth ft + Neat Cement (94 lb bagl5.10 gal water) D Sand Cement sack mix17 gal water <br />D Bentonite (20% solids) D Other <br />Grout Placement Method ❑ Pumped D Free Fall v Other Tremis 0 Retardant / Accelerator (name) 1 <br />PEDESTAL Installed By D Driller D Pump Contractor ❑ Other i <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP 0 Submersible Turbine D 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 />INI 2 UR E NOTICE REQUIRED FOR INSPECTIONS - PIL SE CALL (209697` <br />SIGNED - -_- __...�C = "�^ TRI.EI._NP Y ' `� ///D ATE � <br />Application Accepted By <br />Grout Inspection ByJ <br />Pump Inspection By - <br />Soil Boring Inspection By - <br />COMMENTS <br />EP RTMENT/I7lVE LY <br />Date 3/ Dae9411lii <br />Date <br />Date <br />Are;! 7® Employee ID r <br />!.I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Chec Amount Dat Permit) Invoice # Well ID# <br />Codes Info _ B emitted Service Request 9 <br />EHD434e 11141110 WELL /PUMP PERMIT <br />