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WELL/PUMP PERMIT 120152023.001A <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 1000 Pavilion Parkway CITY/ZIP Tracy, 95304 m <br /> 0 <br /> 0 <br /> CROSS STREET Robertson Drive APN 212-290-47 PARCEL SIZE 2.77AcreAND USE APPLICATION# z <br /> m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Kleinfelder PHONE 209-948-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 <br /> SUBCONTRACTOR California Geotech PHONE 831-634-1964 <br /> SUBCONTRACTOR ADDRESS 3987 FIRST ST STE E CITY/STATE/ZIP Livermore. CA 94551 <br /> LICENSE !XC-57 i C-61 i D-09 i other NUMBER 812382 EXPIRATION DATE 9/30/2014 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i I Domestic/Private I! Irrigation/Agricultural i 1 Industrial -i Water Quality Monitoring X 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 i I New Well i Replacement Well D Well Alteration/Modification 0 Other <br /> I i Monitoring Well(s) #of wells r Soil Boring(s) #of borings I Geotechnical 1,'j #of borings <br /> I-I Out-Of-Service Well I Out-Of-Service Well Renewal L Cross-Connection Repair <br /> I i New Pump Pump Replacement Pump Repair II — <br /> WELL CONSTRUCTION <br /> tilkviftu <br /> Drilling Method Mud Rotary I Air Rotary XAuger Cable Tool 0 Push Poin t C er <br /> Proposed Well Depth 5 ft Excavation -4 in diameter rtmRacafy hIav&e a4jj Ejt in diameter <br /> I Conductor Casing in diameter / Conductor Casir?pQ `�^t" �11c l���t�}� <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5 10 gal _gjnnsack mix/7 gal water <br /> Bentonite(20%solids) XOther SAII <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor - Other <br /> Concrete Pedestal Dimensions:Width ft 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 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Saeed Parsa ���. t _ ` — TITLE Project Engineer DATE g/6/9014 <br /> A <br /> r, h <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ) ` 3 Date Area_QE 7,cQ-LI1 Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 4M6 WELL/PUMP PERMIT <br /> 8/04/08 <br />