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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 16900 West Schulte Road CITY/ZIP Tracy, 95376 m <br /> 20943001 D <br /> CROSS STREET Hansen Road APN PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME Albertsons/Safeway PHONEEn <br /> OWNER ADDRESS 16900 West Schulte Road CITY/STATE/ZIP Tracy,CA 95376 <br /> CONTRACTOR Gregg Drilling LLC PHONE (925)313-5800 <br /> CONTRACTOR ADDRESS 950 Howe Road CITY/STATE/ZIP Martinez,CA 94553 <br /> SUBCONTRACTOR/CONSULTANT Leighton Consulting, Inc. PHONE (949)250-1421 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 17781 Cowan CITY/STATE/ZIP Irvine,CA 92614-6009 <br /> LICENSE Y C-57 ❑ C-61 D-09 Other NUMBER 1044456 EXPIRATION DATE 9/30/22 <br /> BILLING PARTY: 7 OWNER CONTRACTOR X SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: C 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 /> (Geotechnica-7 Public Water System <br /> Engineering If different from Owner: Water System Name Contact Name or Phone Number <br /> Explerat GI;) <br /> TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical 14 #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 i Mud Rotary Air Rotary 2 Auger I Cable Tool Push Point i Other <br /> Proposed Well Depth 5-50 ft Excavation 8-inch in diameter [I Open Bottom i I Gravel Pack/Gravel Size in diameter <br /> (Solt Test Borings) <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic I' Stainless Steel 1 i Other <br /> Grout Seal Depth ft x Neat Cement(94 Ib bag/5 10 gal water) F1 Sand Cement sack mix/7 gal water <br /> i i Bentonite(20%solids) I i Other <br /> Grout Placement Method X Pumped ❑ Free Fall i l Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By I_I Driller ❑ Pump Contractor Other <br /> (Not Applicable) Concrete Pedestal []Dimensions:Width ft Length ft Thick in I i Christy Box -i Stove Pipe <br /> PUMP ❑ Submersible Turbine I] 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 /> INIMUM�48HO�URADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SI D 1-E. E TITLE Engineer DATE June 10, 2021 <br /> E L N <br /> R <br /> { D PA TMENT USE ONLY _- <br /> Application Accepted By ' Date ( Z I Area le-lq <br /> Employee ID# <br /> Grout Inspection By Date ❑ SPECIALWell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 20Zk constructed Well Pt h ft <br /> COMMENTS f �� <br /> L <br /> PE SC Received <Q±ecAmount Date Permit/ Invoice# Well ID# <br /> Codes Info Ely, Cash RemittedService Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />