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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 />NUN-KEFUNDABLE PERMIT L;ALL (ZUU) UbJ-Ib9f FOR INSPECTIONS tXVIKt5 l YEAR FROM DATE ISSUED <br />JOB ADDRESS Hwy 88 PM 13.10-14.50 (Caltrans Right -of -Way) CITY/ZIP Lockeford, CA, 93426 <br />CROSS STREET Locke Road APN APN 05430-031 PARCEL SIZE 3.33 LAND USE APPLICATION # Unknown <br />OWNER NAME Caltrans - Division of Engineering l � / U/41M Y 1tLIpHONE (916) 277-1040 <br />OWNER ADDRESS 5900 Folsom Boulevard ����5 �Q�[�t.�G(y � C`iTY STATE/ i acramento, CA 95819 <br />CONTRACTOR Joe Zilles/Kleinfelder, Inc. LL PHONE (916) 336-1701 <br />CONTRACTOR ADDRESS 2882 Prospect Park Dr., Suite 200 CITY/STATE/ZIP Rancho Cordova, CA 95670 <br />ADDRESS <br />LICENSE 0 C-57 I C-61 I. D-09 I Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 467252 EXPIRATION DATE 12/31/2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE I Domestic/Private I Irrigation/Agricultural I Industrial I Water Quality Monitoring ■ Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK F New Well C Replacement Well I Well Alteration/Modification t Other <br />I Monitoring Well(s) # of wells I Soil Boring(s) # of borings E Geotechnical One (1) # of borings <br />I Out -Of -Service Well I Out -Of -Service Well Renewal I Cross -Connection Repair <br />I New rump I rump Keplacement i rump Kepalr I Kalse wen casing <br />WELL CONSTRUCTION <br />Drilling Method I Mud Rotary I Air Rotary ■ Auger I Cable Tool I Push Point I Other <br />/ In u <br />Proposed Well Depth.,4/�_ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />in diameter <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel I Plastic I Stainless Steel I Other <br />Grout Seal Depth ft ■ Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) I Other <br />Grout Placement Method ■ Pumped I Free Fall ■ Other tremie full depth I Retardant / Accelerator (name) <br />PEDESTAL Installed By F Driller I _ Pump Contractor F Other <br />I Concrete Pedestal I Dimensions: Width ft Length ft Thick in I Christy Box I Stove Pipe <br />PUMP I . Submersiblel Turbine I 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Joseph D Zilles Professional Geologist (No. 7787) <br />SIGNED TITLE DATE <br />T <br />1 <br />m <br />D <br />O <br />O <br />m <br />m <br />N <br />N <br />ll D E A TM ENT USE ON LY <br />Application Accepted By59VI,. Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date ((I <br />COMMENTS <br />Area Employee ID#� <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received e—c kf Amount Date Permit/ Invoice # Well ID# <br />Codes Info B ash Remitte Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />