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C:r:rP.rS WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 aha EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466.3420 <br /> NON-REFUNDABLE PERMIT www.slgoy.orglend EXPIRES 1 YEAR FROM DATE 13SUFD <br /> JosADORESS �Qy(3 /rlrt, ell 38.021040'.Loa:.121,363676* aTYruP Stockton,CA,95206 <br /> CROSS STREET_Mariners Dr/Hammer Ln APN 0!_71-260-010 .L^K <br /> PARCELSInzE 5-0-._LAND WLIC <br /> E APPATIONi Unknown <br /> r) <br /> ,YNER NAME Adam Levin er eb ChaiifS Qnd C.,WA / _.-..,.... PHONE_ (650)492.0934 <br /> I 1+ <br /> �Dl'alLY.ADDRESS 40 Hawthorne Avenue�QiEJje, <br /> j4dhaVipr sT CmISTATEmP Los Altos,CA 94022 l J0,q,L+� CL9 1�O <br /> CONTRACTOR Gregg Drilling,LLC PHONE (925)313-5800 <br /> CONTRACTOR ADDRESS 950 Howe Road CITYISTATE2211'Martinez,CA 94553 <br /> $I/BCONTRACTOR/CONSULTANT Klelnfelder,Inc '_ _ PHONE (209)993-2269 <br /> SUBCONTRACTOR/CON3ULTANT ADDRE33 2001 Arch Airport Rd,Suite 100— CITY/STATEmP Stockton,CA 95206 <br /> LICENSE E C-57 C-61 0.09 0910 _— NUMBER 10444514 EXPIRATION DATE 09/30120_2_2 <br /> Bill NG PARTY: I OWNER •I CONTRACTOR 111 SUBCONTRIICTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:: Generat Mineral/Coliform Bacteria(4391), Dibromochloropropane(4392)I Arsenic(4393) <br /> --- ---- ------------------ - <br /> INI NOED USE Domestic/Privale Inigation/Agrlcullural Industrial ,Water Quality Monitoring 0 Soil Sampling/Characteriialion <br /> Public Water System <br /> II dSerenl nom Owner Wew System Name Contad Name or Phwe Number <br /> TYPE OF WORK I I New Well Replacement Well r I Well Aheration/Modilcation I Other — <br /> Monitoring Well(s) •of vela I Soil Boring(,) A orbonnos ■GeMechnical two(2) a of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal Cross-Connection Repair <br /> Nem Pump Ptgrip Replacement Pump Rglfm Ralar YVeE C�ulpq_ -_._--- <br /> Wr1L CON3TRUCTI <br /> Drilling Method 1 I Mud Rotary ,i Air Rotary I Auger I Cable Tool Push Point 1 Otho <br /> Propn5ed We" Deoth 45 It Excavation B in diameter �Open Bottom I Gravel Pack/Gravel Size in dinmeter <br /> Conductor Casing in diameter / Conductor Casing Depth _n <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 45 R ■Neat Cement(941D 4ag/5-10 gai water) Sand Cement sack mixn gat Wafer <br /> Bentonite(20%Bolds) E 00w,up to S:IHHdulllly <br /> Grout Placement Method E P1Krrped Free Fal 0 Other TrertlfeFull Depth Retardant/Accelerala inanr.) <br /> PEDEEITAL Installed By Diller 1 Pump Contractor I! Other <br /> I Concrete Pedestal'.101mis illons:Widthf1 L -- — <br /> ergtll S M Christy BoX i:Slow Pipe <br /> IPu•AP Submersible Turbine I I Other HP Pump Sel___R Stand"Water Level <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 COMP NATION L WS <br /> MI 4DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769" <br /> SIGNED Tlrteakinm """1011313 F <br /> DATE NI s-0 <br /> D D <br /> F' o <br /> D <br /> SEE ATTACHED BORING LOCATION MAP / Stv <br /> 04 <br /> h �Ro <br /> O6 i q�NTY <br /> MFHT <br /> tI L.J.-I <br /> it <br /> DEPARTMENT USE NLY 1 xk.��y7 <br /> Application Accepted By L Dale Z ?1 Arena 5T • --Employee[DO_ A s <br /> Grout Inspection By Dale SPECIAL Well Permit <br /> Pump Inspectlon By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received C— hi Nf untsn <br /> Codes Info Ca Rimlttid ' rr <br /> Semi Re eat S lnV0i"S Will ION <br /> bC? ► - - - <br /> CH043-M Sitingtg — -- — !ask sr�3� --- WELL JPUMP PERMrr <br /> i <br />