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:SS3tiaaV sack mixI7 gal water <br />WELL CONSTRUCTION <br />Drilling Method I Mud Rotary I Air Rotary Auger Z Cable Tool = Push Point I Other <br />Proposed Well Depth 50 ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br /> <br />= Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 6 In Thickness/Gauge/ASTM Sched I Steel '2 Plastic Stainless Steel Other <br />Grout Seal Depth 5° It J Neat Cement (94 lb bag/5-10 gal water) I Sand Cement <br />Bentonite (20% solids) .. Other <br />Grout Placement Method El Pumped :. Free Fall I Other = Retardant/ Accelerator (name) <br />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.sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br /> 16701 W. St, Rt. 12 crryaip Stockton, California <br />CROSS STREET Bouldin Island Apu 069-10-001 PARCEL SIZE LiS 1 LAND USE APPLICATIONS <br />OWNER NAME Metro Water District of Southern California PHONE <br />OWNER ADDRESS P0 Box 54153 <br /> CITY/STATE/ZIP Los Angeles, California 9005.4 <br />CONTRACTOR <br /> Cascade Drilling PHONE 916-638.1169 <br />CONTRACTOR ADDRESS 3000 Duluth Street <br /> CITY/STATE/ZIP West Sacramento. California 95961 <br />SUBCONTRACTOR/CONSULTANT Hultgren - Tiflis Engineers <br />PHONE 925'685-6300 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 4085 Nelson Avenue, Suite A <br /> CITY/STATE/ZIP Concord, California 94520 <br />LICENSE k C-57 0 O-61 0-09 Other NUMBER 1058336 <br /> <br />EXPIRATION DATE 09/30/2021 <br />BILLING PARTY: DOWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391):Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE .7 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring :if Soil Sampling/Characterization <br />0 Public Water System <br />It different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well Replacement Well 0 Well Alterabon/Modification = Other <br />0 Monitoring Well(s) <br /> <br /># of wells D Soil Boring(s) Itof borings Geolechnical 9 Rot borings <br />0 Out-Of-Service Well <br /> 0 Out-Of-Service Well Renewal Cross-Connection Repair <br />7 New Piann - Primo Rpolacement n Pump Repair - Raise Well Casing <br />PEDESTAL Installed By -Driller - Pump Contractor - Other <br />Concrete Pedestal :-Dimensions Width It Length It Thick in I Christy Box _ Stove Pipe <br />PUMP Submersible Turbine 1 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 />SIGNED /' 21 Project Manager DATE 1126/21 <br />MINIMUM 4B HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />See Attached <br />PAYMENT <br />RECEIVED <br />JAN 26 2021 <br />SAN JOAQUIN COUNTY <br />FNVIRON MENTAL <br />1-IF ALTH DEPARTMENT <br />DEPARTMENT USE ONLY <br />Application Accepted By ..." /- Z___ Date /1,i 4,/,:' I Area 41 /..:1 4) Employee ID# <br />Grout Inspection By Date <br />Pump Inspection By Date j <br />WAIVER Received <br />• ,1 - .. <br />Soil Boring Inspection By •s 4 tor. .. ... -7 Date al /r: 6 /2-49 d--I Constructed Well Depth ft ., - • <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checkft/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />'-f'3/,) IS 0 <br />/IV <br />II 1 /8 3 l'Ill 4 4- .0‘ 11 -a1/124 MY 0 IP (8 IP> <br />EHD 43-06 6/11,2019 <br /> WELL /PUMP PERMIT <br />SPECIAL Well Permit