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� f <br />WELLIPUMP PERMIT <br />SAN JOAcum COUNTY ENvtRO,NNEN'rAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS Logistics Drive Cm//m�,.P, Stockton, CA 95215 <br />CRossSTREET Arch Road APN 4PARCEL SIZ4Z (,{ 1LANDUSEAPPLICATDN <br />OWNERNAIAECT Reality / (.Ati )Or`i Lco L �� �-T PHONE (949) 431-6400 <br />OwNERAoDRE33 4343 Von Karman Avenue, Suite 200 CnY/STATEILIP Newport Beach, CA 92660 <br />CONTRACTOR H1 Drilling Company PHONE (916) 281-4558 <br />CONTRACTORADDREs 9451 Linda Rio Drive _ CT/sTATEMP Sacramento, CA 95827 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CRY/STATE/ZIP <br />LIOEN3E x C-57 ': C-01 :: D-09 :; Other NUMBER 1006095 ExPtRAnONDATE <br />DoMEsnc WELL SAMPLING: _. General Mineral/Coliform Bacteria (4391) :. DibromochlOrOpropane (4392) :: Arsenic (4393) <br />[INTENDED USE :: DomeSbC/Private IRigation/Agricultural ' Industrial ;: Water Quality Mohitoring x Soil Sampling/CharaUarizabOn <br />Public Water System <br />it 011--d hom 0-- Waco Sy.1— Name C—tad Name a Ph— Number <br />TYPE OF WORK D NOW Well :: Replacement Well Well Alteration/Modification '.: Ocher <br />D Monitoring Wallis) ft of walls : Soil sodng(s) s orbceings x Gebtectinical 5 a or borinp <br />G Out -Of -Service Well .: Out -Of -Service Well Renewal :: Cross -Connection Repair <br />i i New Purnp Pump Replacement : Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary /Auger . Cable Toot : Push Point Other <br />Proposed Wait Depth ZO " 30 ft Excavation in diameter :: Open Bottom :-. Gravel PacklGravel Sizein diameter <br />Conductor Casing in diameter t Conductor Casing Depth ft <br />Weil Casing Diameter _ in Thick n sSIGaugetASTM Shed ' Steel : Plastic . Stainless Steel : Other <br />Grout Seal Depth 2-0 - "� o R Neat Cement (94 /b bag15-10 gal eater) Sand Cement sack mixfl gal water <br />Bentonite (20% solids) :.Other _ <br />Grout Placement Method ; Pumped i: Free Fall Other _ v : Retardant I Accelerator (name) <br />PEDESTAL Installed By r Driller Pump Contractor Other _ <br />Concrete Pedestal Dimensions. Width ft Length ft Thkk in ' Christy Box Stove Pipe <br />Submersible:: Turbine i; Other HP Pump Set ft Standing Water Level tt <br />1 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_ 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN C014PLIANCE WITH ALL <br />WORKERS COP, SATION LAWS. <br />n <br />Fr9 IPt = 2 '-)^"'--.:.DVA'iCc NOTICE REQUIRED EL3R 3A3�SPECT)OP1S PLEASE CALL (209 953%-76/97 <br />Sr <br />SIGNED !-- TITLE CEO DATE ^ �+- ( —� <br />- T-� <br />0 <br />1# 1 <br />ANElvT <br />E'Ve,D <br />' 24 2018 <br />QUIN Cp <br />ONMENT�NN <br />)EpgRT T <br />AP,' TMENT U E O Y <br />Application Accepted By ete Area 1 9 Employee IDk 104~ <br />Grout Inspection By Date I . _ SPECIAL Well Permit <br />Pump Inspection By Date . , WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Data Constructed Well Depth ft <br />EHD 4340 —i—d 4114118 VA -LI A U?d 'PLRWT <br />