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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1968 EAST HAZELTON AVENUE - STOCKfON CA95205 - (209) 468-3420 <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS HIGHWAY 12 PM 1.44 TO 1.64 <br />CmZPi�� <br />CRossSTREET_BOULDIN ISLAND' APN PUBLICR.O.W <br />-PARCEL slu NIA LAND USE APPLICATION p IA _. <br />OWNER NAME CALTRANS <br />PHONE 916.227-1039 <br />OWNER ADDRESS 5900 FOLSOM BLVD <br />_ CmISTATErLP SACRAMENTO CA 9581.9 <br />CONTRACTOR Kleinfelder � _� gA, <br />PNOKE 916-366-1701 <br />CONTRACTOR ADDRESS 2882 PROSPECT PARK DR STE. 200 <br />Cay)STATErbp RANCHO CORDOVA CA_ _956_70_ <br />SUBCONTRACTOR GREGG DRILLING <br />PHONE 925-313-5800 <br />SUBCONTRACTOR AmpEss 950 HOWE RD <br />CrTYISTATVZla MARTINEZ CA 94553 <br />LICENSE f C-57 C•61 D-09 Other <br />NUMBER 485165 EXPIRATION DATE 01 /31/2018 <br />GEOGRAPHICAL INFORMATION. Coordinates X 38-115398 y -121.55815 Township_ Ranges,, Section <br />NTENDED USE DcmosliUPrivato Irrigation;Agricultural Industrial Water Quality Monitoring r Soil Samp4ing1Characterization <br />Public Water System <br />H odferoct Irom OMnrr.-'-P."ar ys nm --WURTTLmeor aa. 7ar <br />TYPE OF WORK New Well Replacement Wolf Wdl Alteration/Modification Other <br />Monitoring Well(s)p of Wells Soil Bonng(s) x d boor°• f Goolechnical 16 <br />Out,Of•Servica Well Out -Olt -Service Well Renewal Cross -Connection Repair <br />sof bcnrya <br />Drilling MethoAUMud Rotary Air Rotary *Aug. Cable Too[ Push Pointy other Punch Core <br />PrcpoL:ed Well Depth it Excavation Up to 6" in diameter Open Bottom %ravel Gravel Size _ in diameter <br />Conductor Casing ' in diameter I Conductor Casing Depth fi <br />Weil Casing Diameter in ThicknesslGaugeJASTM Scher! Steel Plastic Stainless Steel Other <br />Grout Seel Depth 40 fl x Noat Cement J94 lb bag5.10 got walor) Sand Cement sack mixt! gal Water <br />Bentonito (20% solids) Othor <br />,Grout Placement Method Pumped Free Fall "POther Trernie Retardant I Accelerator (name) _ _ <br />PEDESTAL Installed By Driller Pump Contractor Other <br />_ Conereto Pedestal Dlmenslons: Width _ It Length R Thick in Christy Bos Stove Pipe <br />PUMP S.bmsibl. Turbine Ofhut HP Pump Sel h Standing Water Lovel It <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM U q�VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ll�� Tine Geologist DATE 112712017 <br />pq Y <br />./ RF��M FOT <br />'Q4 <br />'44 ,0Q"ti <br />ti of �,y),r <br />6h <br />PA MENT U'iSEE� NLY <br />Application Accepted BIo % /v y Area (trRl _ Employee IDk �(�a <br />Grout Inspection By V ala 6 / l ( SPECIAL Well Permlt <br />Pump inspection By Date WAIVER Received <br />Soil Baring lies. rction By Date Constructed Well Depth 1t <br />COMMENTS <br />PE SC Received <br />Codec: Into By <br />Check#/ Amount Date <br />Cash Ramitted <br />Parml$ Invoice N Well IDO <br />Service Request 0 <br />�W <br />EI101.1 C /r�O . / 629- <br />�YEtt h'INr PENiMr <br />