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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 /> _N <br /> JOB ADDRESS Staten Island CITY/ZIP Staten Island b�DD <br /> CROSS STREET N.Staten Island Rd&W Walnut Grove Rd APN 069-02-019 PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME Reclamation District 38 PHONE 916-441.6850 <br /> OWNER ADDRESS clo Wagner&Bonslgnore,2151 River Plaza Drive,Suite 100 CITY/STATE/ZIP Sacramento,California 95833 <br /> CONTRACTOR Gregg Drilling and Testigg PHONE 925-313.5800 <br /> CONTRACTOR ADDRESS 95OHowe Road \ CITYISTATE/ZIP Martinez,California 94553 <br /> SUBCONTRACTOR Hungren-TIIIIs Engineers\ PHONE 2M85-6300 <br /> SUBCONTRACTOR ADDRESS 4085 Nelson Aven ,Suite A CITYISTATE/ZIP Concord,California 94520 <br /> LICENSE e C-57 ❑C-81 0 D-09 ❑Other NUMBER I0L4456 EXPIRATION DA 09f30l2020 <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)C Ars is(4393) <br /> INTENDED USE ❑Domestic/Private 0 IITigation(Agricullural ❑Industrial 0 Water Quality Monitoring +Soil Sa ling/Characterization <br /> C Public Water System <br /> If 611ferent from O« .. Water System Name Contact N or Phone Number <br /> TYPE OF WORK C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> D Monitoring Well(s) III of IIs 1 Soil Boring(s) aol borings /elI'I. <br /> eotechnical 4 aof bor1n98 <br /> ❑Out-Of-Service Well 0 Out-0f-Service Well Renewal ❑Cross- lion Repair <br /> 0 New Pum D Pum Re laceme D Pum Repair ❑Raisesin <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary 0 Air Rotary ❑Aug ❑Cable Tool ❑Push Point Other Hollow-Stem <br /> Proposed Well Depth Approx 30 ft Excavation in diameter 0 Open Bo m 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter a in Thickness/GaugeM Chad <br /> ❑Ste ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth h v Neat Cement( Ib bagr5-10 gal water) C Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0 Pumped 0 Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length R Thick In ❑Christy Box 0 Stove Pipe <br /> amp ❑Submersible❑Turbine 0 Other HP Pump Sat ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICAT6N/ND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES * REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTOR TATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 URA E NOTICE REQ FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Joe Heavin T ke Senior Engineer DATE 05/28/2019 <br /> DEPARTMENT USE N L Y <br /> Application Accepted By Dale �'/ 'C I C( Area Employee ID# <br /> Grout Inspection By l 1 Date D SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Dep H <br /> C9MMENTS l ' r --re 1tl <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Se ceRe uest# <br /> EHD 43-06 noised 4114118 WELL/PUMP PERMIT <br />