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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 <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 16310 W. Schulte Rd. <br />CrrY21P Tracy / 95377 <br />CROSS STREET Hansen Rd. <br />APN 209-230-26 PARCEL SIZE 0.998 Acre LAND USE APPLICATION # <br />OWNER NAME Williams COmmunlcabons, Inc. <br />PHONE <br />OWNER ADDRESS PO Box 22067 <br />Crry/STATE/ZIP Tulsa, OK 74121 <br />CONTRACTOR Taber Drilling <br />PHONE 916.371.8234 <br />CONTRACTOR ADDRESS 536 Galveston Street <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE R C-57 - C-61 -! D-09 <br />Other NUMBER 969927 EXPIRATION DATE 02.28.2018 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) . Arsenic (4393) <br />NTENDED USE n Domestic/Private n Irrigation/Agricultural a Industrial 7 Water Quality Monitoring Pq Soil Sampling/Characterization <br />i i Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well n Replacement Well I..Well Alteration/Modification ^ Other <br />Monitoring Well(s) # of wells rX Soil Boring(s) 1 # of borings ❑ Geotechnical # of borings <br />n Out -Of -Service Well r Out -0f -Service Well Renewal ICross-Connection Repair <br />Fl New Pump n Pump Replacement F' Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rota n Air Rotary Auger I Cable Tool n Push Point I I Other <br />Proposed Well Depth , ft Excavation in diameter Fi Open Bottom n Gravel Pack/Gravel Size in diameter <br />FI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter '�__ in Thickness/Gauge/ASTM Sched CI Steel I1 Plastic n Stainless Steel I I Other <br />Grout Seal Depth ft pC-Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />n Bentonite (20% solids) I I Other <br />Grout Placement Method ❑ Pumped Free Fall FI Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller n Pump Contractor C Other <br />F) Concrete Pedestal F! Dimensions: Width ft Length ft Thick in n Christy Box n Stove Pipe <br />PUMP ❑ Submersible[] Turbine r] 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 />11AI�UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE VP / Exploration Coordinator DATE 01.26.2018 <br />N <br />m <br />D <br />°o <br />m <br />m <br />�p <br />s� <br />NEP��r V Application Accepted By 7u— Date I o2� Area C Employee ID# hl' Y4117 6 <br />Grout Inspection By Date I , SPECIAL Well Permit <br />Pump Inspection By Date I WAIVER Received <br />Soil Boring Inspection By Date Z Constructed Well Depth ft <br />COMMENTS <br />EH043-06 8/01/16 WELL/PUMP PERMIT <br />4D <br />L1/! <br />