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WELL/PUMP PERMIT <br /> SAh 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 1950 Port Road A CITY/ZIP Stockton/95203 m <br /> D <br /> CROSS STREET Port Road 2 o APN 14500200041 PARCEL SIZE 162 acre�AND USE APPLICATION# <br /> OWNER NAME �C us(PwyI PHONE l OJ W <br /> // <br /> OWNER ADDRESS 0 ' !�(/ "/ CITY/STATE/ZIP � `�V � Z <br /> CONTRACTOR Kleinfelder PHONE 209.948.1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/ZIP Stockton/CA/95206 <br /> SUBCONTRACTOR V&W Drilling PHONE 209.469.7700 <br /> SUBCONTRACTOR ADDRESS 1133 Blackhurst Dr. CITY/STATE/ZIP Galt/CA/95632 <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392) - Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X 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 X Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 100 It Excavation 4 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 X Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X 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 /> NI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Project Geologist DATE 1/22/2019 <br /> .^ qF ^ \ : <br /> 0 <br /> s <br /> y <br /> � m. <br /> Z10 <br /> Sm <br /> �V <br /> =slue:' - <br /> EP iRTMENT SE ONLY <br /> Application Accepted By Date 1, Area Employee ID# <br /> 1*VZW <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date 2 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> Z �l <br /> Was car 1-25;_1� 2 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />