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WELL/PUMP PERMIT r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KF-FUNDA13LF PERMIT GALL LU`J U0J-1bU1 FOR INSPECTIONS tAYIKtb l YEAR FROM UATE ISSUED JOB ADDRESS 2121 N Zuckerman Road Crrr21P Stockton/ 95206 CROSS STREET Access Rd APN 12908009 PARCEL SIZE 565 LAND USE APPLICATION # OWNER NAME PG&E PHONE (925) 327-0828 OWNER ADDRESS 6121 Bollinger Canyon Road, t Cm/STATE2IP San Ra / R � Ramon/ ('.A/ 94583 CONTRACTOR Kleinfelder PHONE (209) 948-1345 CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite #100 CITYISTATE/ZIP Stockton/ CA/ 95206 )R Taber nrillinq PHONE (11R) 371-8234 )R ADDRESS 536 CaIVeRtnn Street CITY/STATE21P West Sacramento/ CA/ 95691 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 969927 ExPIRATION DATE 02 2q. 2020 DOMESTIC WELL SAMPLING: , General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Ouality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) u of borings X Geotechnical 3 of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair Drilling Method )(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 50 ft Excavation 4-6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft X Neat Cement (94 Ib bag/5-f0 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall X Other Tremie ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ]Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIM""''" un/10 An%rAulrC 61AT1^1C REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED �� TITLE Staff Geologist I DATE 3/5/2018 Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection B0 COMMENTS Area Employee ID#_� / ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft MMC�M® .. EHO 43-06 6/01116 / --?O31—[ 6 1 WELL/PUMP PERMIT 06�