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r <br /> e <br /> 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 INSPECT1921 V EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7� m <br /> JOB ADDRESS Staten Island 7i5D CIN/21P Staten Island m <br /> D <br /> CROSS STREET N Staten Island Rd&W Walnut Grove Rd APN 069-02-019 PARCEL SIZE4/"/ 66ND USE APPLICATION# p <br /> T�� m <br /> OWNER NAME Reclamation District 38 PHONE 916441-6850 <br /> OWNER ADDRESS c/o Wagner&Bonsignore,2151 River Plaza Drive,Suite 100 CITYISTATE/ZIP Sacramento,California 95833 <br /> CONTRACTOR Gregg Drilling and Testing PHONE 925-313-5800 <br /> CONTRACTOR ADDRESS 950 Howe Road CITY/STATEIZIP Martinez,California 94553 <br /> SUBCONTRACTOR Hultgren-Tillis Engineers PHONE 925-685-6300 <br /> SUBCONTRACTOR ADDRESS 4085 Nelson Avenue,Suite A CITY/STATE/ZIP Concord,California 94520 <br /> LICENSE v C-57 = C-61 = D-09 -Other NUMBER 1044456 EXPIRATION DATE 09/30/2020 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)=Arsenic(4393) <br /> INTENDED USE = Domestic/Private E Irrigation/Agricultural Industrial _Water Quality Monitoring v Soil Sampling/Characterization <br /> = Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Z New Well = Replacement Well =Well Alteration/Modification Other <br /> - Monitoring Well(s) #of wells =Soil Boring(s) #of borings r Geotechnical 15 a of bodngs� <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 E Cable Tool =Push Point , Other CPT <br /> Proposed Well Depth APprox 50 ft Excavation in diameter E Open Bottom _Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched C Steel - Plastic E Stainless Steel :_ Other <br /> Grout Seal Depth it v Neat Cement(94 Ib bag/5-10 gal water) -Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) E Other <br /> Grout Placement Method - Pumped E Free Fall ' Other Tremie = Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller = Pump Contractor - Other <br /> - Concrete Pedestal::Dimensions:Width ft Length it Thick in -_Christy Box E Stove Pipe <br /> PUMP =SubmersibleC Turbine =Other HP Pump Set it 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Chadene Truong TITLE Staff Engineer DATE 02/14/2019 <br /> it I <br /> P yilfieNT <br /> Fj�WgQUI <br /> VIRONAfi <br /> co <br /> tiji <br /> y <br /> N UEPgR MINT <br /> EP RTM NT SE ONLY <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By Date PECIAL 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 heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BS ervice Re ueSt# <br /> EH043-06 revised 4/14/18 WELL/PUMP PERMIT <br />