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P�• <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KLFUNUAt3Lt rtRMI I L ALL ZUti ZOO 3-ybyr FUR IN5PEGTIUN5 tAVIKtb 7 TEAR FROM UATE ISSUED <br />Joe ADDRESS 4239 /4268 Pock Lane CITY/ZIP Stockton 95206 <br />CROSS STREET Boeing Way APN 17934006 /4W934COr- PARCEL SIZE 3.33 LAND USE APPLICATION # Commercial <br />OWNER NAME Trader Joe's inCy PHONE <br />OWNER ADDRESS 800 S Shamrock CITY/STATE/ZIP Monrovia/CA/90106 <br />CONTRACTOR Kleinfelder Inc. PHONE 209-948-1345 <br />CONTRACTOR ADDRESS 2001 Arch -Airport Road Suite 100 CITY/STATE/ZIP Stockton/CA 95206 <br />SUBCONTRACTOR V S W Drilling PHONE (209) 469-7700 <br />SUBCONTRACTOR ADDRESS 1133 Blackhurst Drive Cm/STATE/LP GaIUCA/95632 <br />LICENSE Ia C-57 C-61 D-09 Other NUMBER 720904 EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE - Domestic/Private - Irrigation/Agricultural - Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />- Public Water System <br />If different from Owner: Water System Name o a ame or one um er <br />TYPE OF WORK - New Well Replacement Well - Well Alteration/Modification - Other <br />❑ Monitoring Wells) # of wells 13 Soil Boring(s) # of borings ❑Geotechnical 12 #of borings <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />iNCw rump rump me IacCmBnl rufnp me au md1be vveu Uasur <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary - Air Rotary E] Auger Cable Tool - Push Point - Other <br />Proposed Well Depth 30 ft Excavation 6 in diameter - Open Bottom Gravel Pack/Gravel Size in diameter <br />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 it (] Neat Cement (94 Ib bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) - Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall p Other Tremmie - Retardant / Accelerator (name) <br />PEDESTAL Installed By -. Driller - Pump Contractor - Other <br />- Concrete Pedestal -Dimensions: Width It Length it Thick in - Christy Box - Stove Pipe <br />PUMP Submersible- Turbine Other HP Pump Set it 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 />Mit4IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED I `7 `��'��v TITLE Engineer DATE 1112/2018 <br />Application Accepted Bj; <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />DEPARTMENT 7E 07L Y <br />j,`I <br />Date Area /t4mployee ID# <br />Date Jam/ —/iii ❑ PECIAL Well Permit <br />Date ❑ WAIVER Received <br />Date Constyucted Well Depth It <br />PE SC Received Check#/ Amount Date <br />Codes Into By Cash Remitted <br />Permit/ Invoice# WellID# <br />Service Request # <br />7,24 A G I b <br />9 <br />EHD 43-M <br />4/30/12 <br />WELL /PUMP PERMIT <br />