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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 />NUK-KEFUNUABLE YEKMII %..ALL LUJ J33 -/OJ/ FUK 1N,YEG IIUNS CArlmrI 1 TCAK FKUM ILIA IE IJJUCU <br />JoBADDRESS Median of 1-5 along Stockton Deep Water Channel Bridge crrylzlP Stockton, 95203 <br />CROSS STREET West Fremont Street APN <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Public Right of Way <br />PHONE <br />OWNER ADDRESS NA <br />CrrYlSTATE21P <br />CONTRACTOR Kleinfelder <br />PHONE 916-366-1701 <br />CONTRACTOR ADDRESS 2882 Prospect Park Drive <br />CITY/STATE/ZIP Rancho Cordova, CA 95670 <br />SUBCONTRACTOR Kleinfelder <br />PHONE 916-366-1701 <br />SUBCONTRACTOR ADDRESS 2882 Prospect Park Drive <br />CITY/STATE21P Rancho Cordova, CA 95670 <br />LICENSE 4 C-57 C-61 D-09 Other <br />NUMBER 467252 EXPIRATION DATE 12/31/2019 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring 4 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or one Numoer <br />TYPE OF WORK New Well Replacement Well Well AlteratioNModification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 4 of boring, 4 Geotechnical 10 sof borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method 4 Mud Rotary Air Rotary Auger Cable Tool Push Point I Other 5 Mud Rotary and 5 CPTs <br />Proposed Well Depth 200 It Excavation 4 to 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack m/x/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall [Z] Other Trenlle 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 />PUMP 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 REQLIIRED 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 />SIGNED '- -i-0 "- ' TITLE Geologist DATE 11/7/2017 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />EHD 43-8 <br />4130112 <br />WELL /PUMP PERMIT <br />m <br />m <br />w <br />