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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> Joe ADDRESS 13022 W.Walnut Grove Road CtTy[Zlp Thorton 195686 <br /> D <br /> CROSS STREET Walnut Grove Road and Lamb Road APN 00105028 PARCEL SIZE LAND USE APPLICATION# g <br /> m <br /> OWNER NAME Reclamation District 348 PHONE 916-441.6850 <br /> OWNER ADDRESS d0 Wagner 6 Bonsignors,2151 River Plaza Drive,Suite 100 CmfSTATE/ZIP Sacramento,California 95833 <br /> CONTRACTOR Hultgren-Tillis Engineers PHONE 925-685-6300 <br /> CONTRACTOR ADDRESS 4085 Nelson Avenue,Suite A CITYISTATE/ZIP Concord,California 94520 <br /> SUBCONTRACTOR/CONSULTANT Gregg Drilling and Testing LLC PHONE 925-313-5800 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 950 Howe Road CRY/STATEIZIP Martinez,California 94553 <br /> LICENSE ❑� C-57 C C-61 -D-09 E Other NUMBER 1044456 EXPIRATION DATE 09rWi`2020 <br /> BILLING PARTY: -OWNER G3CONTRACTOR - SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE C Domestic/Private C Irrigation/Agricultural =Industrial -Water Quality Monitoring m Soil Sampling/Characterization <br /> G Public Water System <br /> If d iferent from Owner Water System Name Contact Name or Ph—Number <br /> TYPE OF WORK C New Well C Replacement Well D Well Alteration/Modification m Other 10PU <br /> C Monitoring Well(s) #of wells O Soil Boring(s) #of bonngs m Geotechnical 7 #of borings <br /> G Out-Of-Service Well C Out-Of-Service Well Renewal C Cross-Connection Repair <br /> C New Pump D Pump Replacement C Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method O Mud Rotary C Air Rotary �:Auger D Cable Tool C Push Point ❑� Other Hollow-Stem and CPT <br /> Proposed Well Depth APPmx 60 R Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br /> G Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 2108 in Thickness/Gauge/ASTM Schad C Steel C Plastic C Stainless Steel ❑Other <br /> Grout Seal Depth R m Neat Cement(94 It,beg/5-10 gel water) -Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement Method C Pumped C Free Fall C Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller C Pump Contractor C Other <br /> C Concrete Pedestal CDlmensions:Width h Length ft Thick in C Christy Box C Stove Pipe <br /> PUMP C SubmersibleC Turbine C Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I H VE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINAN S, STATE WS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WI THE CA IF NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATIO L WS. <br /> MINIMUM 48 1­1561JR AD E NOTI REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Joe Heavin TITLE Senior Engineer DATE 08/13/2019 <br /> PA YW, <br /> Aoz 2019 <br /> /'10AQ(//N CC� <br /> Ty�pM�� T)• <br /> T <br /> I It I L <br /> . I DEP RTMENT USEttQNLY <br /> Application Accepted By / / Date D/ZC ( Area 1 r C! Employee ID# <br /> Grout Inspection By Date — SPECIAL Well Permit <br /> Pump Inspection By Date — WAIVER Received <br /> Soil Boring Inspection By Dale C Constructe Well Depth ft <br /> COMMENTS <br /> y . ;, bi I.L, <br /> PE SC Received Check#/ Amount Date PermlV Invoice# Well ID# <br /> Codes Info Cash Remitted Service Ra uest Y <br /> EH04}06 9/11/2019 WELL(PUMP PERMIT <br />