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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 /> rn <br /> JOBADDRESS 1305 Tommydon Street CITY/zIP Stockton,CA 95210 m <br /> D <br /> CROSS STREET Kathleen Drive APN 0940 041 PARCEL SIZE 2.0 LAND USE APPLICATION# <br /> In <br /> t��� <br /> OWNER NAME Kaiser Permanente "dei l .+�{ 1--1:')'1 r gSPI -5 P%NE 0+ <br /> OWNERADDRESS `7n� k.'Sy' oo IJtCI/STATE/ZIP r krh�CA952" gyG�a <br /> PI <br /> CONTRACTOR Construction Testing Services(CTS) PHONE 925-462-5151 <br /> CONTRACTOR ADDRESS 2118 Rheem Drive CITYI$TATE/ZIP Pleasanton,CA 94588 <br /> SUBCONTRACTORICONSULTANT California Geotech PHONE 831-634-1964 <br /> SUBCONTRACTORICONSULTANT ADDRESS 6886 Village Parkway CITY/STATE/ZIP Dublin,CA 94568 <br /> LICENSE X C-57 C-61 D-09 IOther NUMBER 812382 ExPIRATION DATE <br /> BILLING PARTY: .OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) _Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> i 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 /> Monitoring Well(s) #of wells U Soil Boring(s) #of borings X Geotechnical 2 #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 X Auger Cable Tool Push Point Other <br /> Proposed Well Depth 21.5 It Excavation 4 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 Sched Steel Plastic Stainless Steel - Other <br /> Grout Seal Depth 21.5 ft X 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 X Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Driller I Pump Contractor i 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMA"8 HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE 60"Y-'ftC-� DATE <br /> Boring B- <br /> .... <br /> -,dAT — r <br /> Boring B-2 <br /> M1 <br /> �*RM <br /> TY <br /> NT <br /> DEPARTMENT USE ONLY Il <br /> Application Accepted By Date 11 Area OEmployee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date M d'% \ In Constructed Well Depth ft <br /> COMMENTS Z E�9S�� TSeo1Jfll� <br /> Irit'o-q—T*Q tw S <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> pa o NAVA MIM&W i <br /> ���WELL!PUMP PERMIT <br /> EHD 43-06 6/112019 <br />