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1 " <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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Staten Island MZ-5b All ��'S� Staten Island to <br /> JOB ADDRESS ,y CITY/ZIP m <br /> CROSS STREET N.Stales Island Rd&W Walnut Grove Rd ApN 069-02-019 PARCEL SIZ 'O LAND USE APPLICATION# p <br /> �].� n � ,-u m <br /> OWNER NAME ReGamalion District 38 n/7�� /IY.4I>zf� / {�/ PHONE 916441-6850 In <br /> OWNER ADDRESS Go Wagner&Bonsignore,2151 River Plaza Drive,Suite-11"'00����-++/'���r01*Ty STATEIZIP 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/STATEIZIP Concord,California 94520 <br /> LICENSE / C-57 - C-61 C D-09 - Other NUMBER 1044456 EXPIRATION DATE 09/30/2020 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)�j Dibromochloropropane(4392)=Arsenic(4393) <br /> INTENDED USE - Domestic/Private Irrigation/Agricultural Industrial -Water Quality Monitoring �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 /> - MonitoringWell(s) #of wells -SoilBoring(s) of borings i Geotechnical 6 #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 ❑Push Point _ Other <br /> Proposed Well Depth APprox 50 ft Excavation in diameter C Open Bottom -Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter a in Thickness/Gauge/ASTM Schad G Steel - Plastic -Stainless Steel C Other <br /> Grout Seal Depth ft +Neat Cement(94 Ib bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br /> = Bentonite(20%solids) -Other <br /> Grout Placement Method = Pumped C Free Fall E Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller - Pump Contractor - Other <br /> - Concrete Pedestal❑Dimensions:Width ft Length It Thick in E Christy Box C 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Charlene Truong — TITLE Staff Engineer DATE 02/14/2019 <br /> PA YjWFNT <br /> CE jVF p <br /> MAR <br /> 04 2019 <br /> fOAQUIN C <br /> H V>RCNM� OUNPY <br /> T M�EPAR MENT <br /> it <br /> D ji PA JR TM ENT U E N L Y <br /> Application Accepted By Date AreaEmployee ID# <br /> Grout Inspection By Date 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 Che Amount Permit/ <br /> Codes Info ash litemitted Date Service Request# Invoice# Well ID# <br /> zRaZ 19 ONO;5t+I <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />