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�y <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EASTHAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> 1 I NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7-15Z90T <br /> JOB ADDRESS Mountain House Parkway CITY/ZIP TRACY 95377 a <br /> O <br /> CROSS STREET Berkeley Road APN 209-120-09 PARCELSIZE 378.88 LAND USE APPucanON#COMMERCIAL <br /> N <br /> OWNER NAME Prologis Inc PHONE In <br /> OWNER ADDRESS 60 STATE ST#1200 CITY/STATE/ZIP BOSTON MA 02109 <br /> CONTRACTOR Kleinfelder Inc. 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 3806 Duck Creek Dr CITY/STATE/ZIP Stockton,CA 95215 <br /> LICENSE m C-57 -C-61 D-09 Other NUMBER 720904 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <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 Nam or ne um r <br /> TYPE OF WORK - New Well - Replacement Well -Well Alteration/Modfication - Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of bodngs D Geotechnical 25 If of borings <br /> -Out-Of-Service Well -Out-Of-Service Well Renewal - Cross-Connection Repair <br /> -New Pum - Pump Replacement - Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary -Air Rotary 0 Auger 7 Cable Tool - Push Point Other <br /> Proposed Well Depth 30 ft Excavation 6 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 Schad - Steel - Plastic - Stainless Steel -Other <br /> Grout Seal Depth 30 ft Neat Cement(94 Ib bagl5.10 gal water) - Sand Cement sack mixll gal water <br /> - Bentonite(20%solids) - Other <br /> Grout Placement Method❑Pumped ❑Free Fall ❑Q Other Tremmie -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 /> MI�IMU�ki 224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED,�J��Y`�!/' "' ���� TITLE Engineer DATE 8102/2017 <br /> V,l <br /> PA Y� <br /> RFc��VN� <br /> �® <br /> ASG 3 2011 <br /> �CTyq�Nti1EA( Nry <br /> �EpgRrue <br /> EP RTMv r <br /> ENT U E O Y <br /> Application Accepted ate V I Area Employee ID#� <br /> Grout Inspection By Date qUSPEqClAL ell Permit <br /> Pump Inspection By �^ Date .n� ❑ WAIVER Received <br /> �-f jo Sec'-o y)I Soil Boring Insp ,tion By l afl O�Ou �f Date 2 !i+w Constructed Well Depth ft <br /> CrO1M NTS r uN c »+v iTo W rCvt' <br /> Yv e a(r Kgv'�4 <br /> L9✓1 g/C PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> ii I Codes Info B Cash emitted Service Re uest# <br /> En WELL/PUMP PERMIT <br /> 4/3301120/12 G.[J 7 <br />