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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 821 W.8th Street&715 W.8th Street CITYIZIP Stockton,CA 95206 m <br /> D <br /> Lever Boulevard 163-14-012 PARCEL SIZE 8.8 acres LAND USE APPLICATION# o <br /> CROSS STREET APN <br /> M <br /> M <br /> OWNER NAME Stockton 1313 Petroleum Inc PHONE <br /> OWNER ADDRESS P.O. BOX 3820 CITY/STATE/ZIP Turlock,CA 95381 <br /> CONTRACTOR Middle Earth Geo Testing, Inc PHONE 714-633-5025 <br /> CONTRACTOR ADDRESS 954 N Lemon Street CITY/STATE/ZIP Orange,CA 92867 <br /> SUBCONTRACTOR California Push Technologies (CPT Inc) PHONE 510-357-3677 <br /> SUBCONTRACTOR ADDRESS 820 Aladdin Ave CITY/STATE/ZIP San Leandro, CA, 94577 <br /> LICENSE / C-57 C-61 D-09 Other NUMBER 899451 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigationi'Agricultural Industrial Water Quality Monitoring / Soil Sampling/Characterization <br /> Public Water System <br /> L — If different from Owner. Water System Name Ccn:act Name or Phore Number <br /> TYPE OF WORK ,:1 New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells / Soil Boring(s) z of borings / Geotechnical 2 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Z Push Point Other <br /> Proposed Well Depth 50-100 ft Excavation 2 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft / Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other CPT will be grouted per San Joaquin County guidelines <br /> Grout Placement Method Pumped / Free Fall / Other Tremie(if needed) 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 COMPENSAT &UDftCTI10E <br /> N1iNIfViUlwl 4i N REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 p <br /> SIGNED TITLE nn. _ DATE L4-I o <br /> I V1 <br /> sill <br /> LL C <br /> i <br />