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SS3i100V 311S 01 E. Dr. Martin Luther King Jr. Blvd., Stockton, CA WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 1801 E. Dr. Martin Luther King Jr. Blvd. cmazie Stockton, CA 95205 <br />OIAINER NAME Gillson Trucking <br />OWNER ADDRESS <br />CROSS STREET South B Street APN 155-140-*5 <br />1950 E. Miner Avenue, Suite A /zi,:,/ cAfilnA <br />-1-15 <br />CA414"114',4- <br />PARCEL SIZE er. 71-C LAND USE APPLICATION # NA <br />trIrf--arAreizip Stockton, tA 95205 <br />NE (209) 603-0525 <br />CONTRACTOR GeoEX Subsurface Exploration, Inc. PHONE (916) 799-8198 <br />CONTRACTOR ADDRESS 1510 Madera Drive crry/SrArerzip Dixon, CA 95620 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-61 0-09 Other NUMBER 954267 EXPIRATION DATE 6/30/2018 C-5. <br />Dom ESTIC WELL SAMPLING: General MineraVColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />Dornestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Cil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />New Well Replacement Well Well Alteration/Modification Other Exploratory drill holes <br />INTENDED USE <br />TYPE OF Worn( <br />Monitoring Well(s) 0 /t of wells Soil Boring (s) NA Par borings Geotechnical 8 Ref beings <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />WELL CONSTRUCTION <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rory Cable Tool Push Point Other <br />Proposed Well Depth 5-50 ft Excavation 8.25" in diameter Open Bottom Gravel Rack/Gravel Size in diameter <br />Conductor Casing NA in diameter / Conductor Casing Depth NA ft <br />Well Casing Diameter NA in Thickness/Gauge/ASTM Sched NA Steel Plastic Stainless Steel Other <br />Grout Seal Depth 5-50 fteat Cer< nent er Sand Cement sack mix/7 gal water <br />Bentonite (20%_ solids) Other <br />Grout Placement Method Cumped) Free Fall Other NA <br /> <br />Retardant / Accelerator (name) NA <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width NA ft Length NA ft Thick NA in Christy Box Stove Pipe <br />'PUMP Submersible Turbine Other NA HP NA Pump Set NA ft NA Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK. WILL BE DONE IN ACCORDANCE WITH <br />SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED <br />LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN <br />COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br />MINIMUM H DVANCE NOTICE REQUI5.11X9R IN7CTIOri_PLEASE C L (19) 953 97 <br />SIGNED Trni DATE <br /> CEIVE 4 <br /> <br />(7A-co-EP APR 0 2018 <br />ONMENTAL NEI; rTRMIT/SERV10E: <br />EN <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Bonng Inspection By <br />COMMENTS <br />Area ( _,..41k Employee IDS/ 0/644:1 <br />Data SPECIAL Well Permit <br />Date WAIVER Received <br />Date Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received ChecIdli <br />, Ca Ash _ <br />Amount <br />Remitted Date Permit/ <br />Service Request St InvopERMI rj 431'- I qD 6 Z ( 2,_. /Ay r _ A 47 ' 7 i 4 )PIC)O 3 `,;s i ?) i <br />EXPIRE <br />BID 43-06 8/01/16 <br />(/(54i-3. WELL (PUMP PERMIT