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WELL/PUMP 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 /> JOB ADDRESS 26901 Hansen Road(See map) Clil Tracy,CA 95377 _ <br /> j� D <br /> CROSS STREET None APN 209-110-106-60 PARCEL SIZE_15.3rlAt4D USE APPLICATION# a <br /> m <br /> OWNER NAME Costco Wholesale PHONE(425)313-6052 i <br /> OWNER ADDRESS 999 Lake Drive CITY/$TATE/ZIP Issaquah,WA 98027 <br /> CONTRACTOR V&W Drilling PHONE (209)469-7700 <br /> CONTRACTOR ADDRESS 3806 Duck Creek Drive CITY/STATE/ZIP Stockton,CA 95215 <br /> SUBCONTRACTOR/CONSULTANT Kleinfelder,Inc. PHONE(408)840-1038 <br /> SUBCONTRACTORICONSULTANT ADDRESS 380 North First Street,Suite A CITY/STATEIZIP San Jose,CA 95112 <br /> LICENSE XC-57 C-61 I D-09 11 Other NUMBER 720904 EXPIRATION DATE April 30,2022 <br /> BILLING PARTY: OWNER L CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)El 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 L Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells X Soil Borings)_ I #of bonngs Geotechnical #of borings <br /> Out-Of-Service Well C 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 X Auger Cable Tool ❑Push Point Other A <br /> Proposed Well Depth fie'R:r ft Excavation _in diameter L Open Bottom Gravel Pack/Gravel Size in diameter P <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel L Plastic Stainless Steel LiOther <br /> Grout Seal Depth��ft (Neat Cement(94 Ib bag/5-10 gal water) L Sand Cement sack mix/7 gal water �O <br /> Bentonite(20%solids) OtherUG Z5 <br /> Grout Placement Method X Pum ed X Free Fall Other Retardant/Accelerator name 20?O <br /> Installed By Driller Pwnp Contractor Other /I <br /> Concrete Pedestal Dimensions Width ft Lengt�l1 ft Thick in Christy Box Stove <br /> PUMP Submersible 7Lrb'uie Other HP Pump Set ft StandingWaterLevel ft RN�/�T� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN TMF/1/)- <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 I TITLE Environmental Scientist-Kleinfelder DATE 08/21/2020 <br /> DEPARTMENT SE ONLY <br /> Application Accepted By Date 6t Area �� Employee ID# 3k <br /> Grout Inspection By __ Date SPECIAL Well Permit <br /> Pump Inspection By Date > WAIVER Received <br /> Soil Borin�specfl n Byn By 1 Date— S 1 Z� Constructed Well Depptth ft <br /> COMMENTS /6�er��e- eil 10 br L fd Wink�� wirr44 is Vf�Y47 IA the, 130re )P <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Reqptv_ <br /> 37d p Sc., ; 5-k- YLLCt <br /> EH043-M 6/1112019 70Y 73 WELL!PUMP PERMIT <br />