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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 />Ir WI7'Ikel-UNUAGLC rCNMII WWVI <br />JOB ADDRESS 16701 W S1 RI 12 <br />CROSS STREET 6ouldin Island APN 069-10-001 <br />OWNER NAME Metro Water District of Southern California <br />OWNER ADDRESS PO Box 541.53 <br />CONTRACTOR Conetec <br />CONTRACTOR ADDRESS 820 Aladdin Avenue <br />TRACTORICONSULTANT Hultgron - Tlllis Engineers <br />TRACTOR/CONSULTANT ADDRESS 4085 Nelson Avenue. Suite A <br />v C-57 C-61 D-09 Other <br />PARTY: OWNER CONTRACTOR <br />I=AI'IKtb T YEAR FROM L1ATE ISSUED <br />CITY/ZIP Stockton, California <br />.CEL SIZE r� `� LAND USE APPLICATION # <br />PHONE <br />CITYISTATEIZIP Los Angeles. California 90054 <br />PHONE 510-357.3677 <br />CITYISTATEIZIP San Loandro. California 94577 <br />PHONE 925-685-6300 <br />CITYISTATE/ZIP Concord, California 94520 <br />NUMBER 1049248 EXPIRATION DATE OV3112021 <br />V SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENOED USE Dome stic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring / Soil Sampling/Characterization <br />Public Water System <br />If different from 0—er Water Syslem Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other 22 CPTs <br />Monitoring Well(s) # of wells _ Sod Boring(s) a of borings I Geotechnical rr of borings <br />Oui-Of-SeIVICe Well Out -Of -Service Well Renewdl Cruss-Cunnechun Repdu <br />New rump rump Kepiacemem rump Kepair Kaise vven casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 2 Air Rotary Auger Cable Tool Push Point v Other CPT <br />Proposed Well Depth 50 ft Excavation in diameter Open Bottom Gravel PackiGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 2 in ThicknessiGauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 50 fl v Neal Cement (941b bag/5-f0 gal wafer) Sand Cement sack rnix17 gal water <br />Bentonde(20%solids) Other <br />Grout Placement Method ❑Pumped Free Fall Other Retardant 1 Accelerator (name) <br />PEDESTAL Installed By - Driller - Pump Contractor - Other <br />Concrete Pedestal Dimensions Width It Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set fl 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />/, <br />Application Accepted By/ Date ✓ �' y Area i / Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Sod Boring Inspection By Date z- Constructed Well Depth ft <br />COMMENTS <br />PE SC R ceived <br />Codcs Info <br />Lthick0l Amount <br />Cash Remitted <br />Date PermiU Invoice # Well IDN <br />Service RC uest# <br />Sal <br />rc� <br />,, p, V )C LH <br />EHD43M Glii2l1g WELL+PUMP PERMIT <br />a <br />N `ENT <br />NVtomC® <br />2021, <br />IN COUNTY <br />(MENTAL <br />PARTMENT <br />