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gle TA <br />M "ER <br />TH EA_ <br />C ES <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209)468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />NON-REFUNDABLE PERMIT 1..../ALL kLvv, vi.1.1-1 ‘JJ, rvis Elmve .—.... .... ... <br />CI <br />2651 S. Airport Way CITY/L i—I IP Stockton/95206 ) <br />ADDRESS ADDRESS C JOB <br />169-120-02 7.6 , <br />PARCEL SIZE LAND USE APPLICATION # <br />C 7 r S.Airport/lOth A pN c CROSS STREET <br />Real City LLC PHONE 510 — 7 5 2..- 4 14 P c <br />NAME OWNER <br />1730 Sabre St. Hayward/CA 94545 CITY/STATE/Z1P <br />OWNER ADDRESS <br />Advanced GeoEnvironmental, Inc. PHONE 209-467-1006 <br />CONTRACTOR <br />837 Shaw Road Stockton/CA/95215 CITY/STATE/ZIP <br />CONTRACTOR ADDRESS <br />All Well Abandon PHONE 916-363-9355 <br />SUBCONTRACTOR <br />3369 Fitzgerald Rd. CITY/STATE/ZIP <br />Rancho Cordova/CA/95742 <br />L <br />SUBCONTRACTOR ADDRESS <br />NUMBER 680227 EXPIRATION DATE 11/30/2016 <br />41110 C-61 D-09 Other LICENSE <br />Township Range Section <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Industrial Water Quality Monitoring CSZTE§amPling/Characterizatic — <br />INTENDED USE 0 Domestic/Private Irrigation/Agricultural <br />C Public Water System Name Phone Number <br />If different from Owner. Water System Name Contact or <br />C 1 Other <br />TYPE OF WORK 1_7 New Well Replacement Well Well Alteration/Modification <br /># of borings # of borin *it X Geotechnical 5 <br />C Monitoring Well(s) # of wells E Soil Boring(s) <br />C Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />C New Pump Pump Replacement L] Pump Repair CI Raise Well Casing <br />ti <br />WELL CONSTRUCTION <br />Cable Tool Push Point Other <br /> <br />Drilling Method J Mud Rotary Air Rotary X Auger <br /> <br />50 8 Open Bottom Gravel Pack/Gravel Size <br />Well Depth ft Excavation in diameter Proposed <br />'1 in diameter / Conductor Casing Depth ft Conductor Casing <br />Steel Plastic Stainless Steel Other <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />50 lb bag/5-10 water) Sand Cement sack mix/7 gal water <br />Grout Seal Depth ft X Neat Cement (94 gal <br />Other Bentonite (20% solids) l . <br />Retardant / Accelerator (name) <br />Grout Placement Method XPumped 7 Free Fall Other <br />Contractor Other PEDESTAL Installed By Driller Pump <br />ft Thick in Christy Box Stove Pipe NA 0 Concrete Pedestal Dimensions: Width ft Length <br />Pump Set ft Standing Water Level ft <br />NA 1 - Submersible 0 Turbine Other HP PUMP —---------------- ..„-...-.., ,,.. . .. nr-%Km im ArrnpnANr.F WITH SAN <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION <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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 144444615 d- CJL- PROJECT MANAGER 03 /17 /2016 <br />TITLE DATE <br />- <br />;Ted) <br />110134 <br /> GEO-Teti RI <br /> N LY <br />AU A 0 A <br /> <br />&Il TA 7 20 16 <br />MR_ <br />Zoliv ,to 4 <br />-c.. a <br />ke , ,v ill , . N <br />A EPA tir4 t . <br />DEPARTMENT USE .ONLY <br /> <br />i \ __Date \., (AV k-7 0 ‘ ( Vk <br /> / , <br /> <br />Application Accepted By <br />Area Employee ID# 1 .' 7, , --,' ',,.` <br /> <br />Grout Inspection By Date H SPECIAL Well Permit <br /> <br />Pump Inspection By Date 0 WAIVER Received <br /> <br />Soil Boring Inspection By Date <br /> Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />ChecIsW <br />Cash <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request # <br />' Well ID# <br />IT <br />1,‘ ' DLL-, IL) -M1 7)-174 5g00 7 -1-‘3(P1M <br />EXEIRED <br />kA/P1 I 1511TOP PFRMIT <br />EHD 43-06 <br />4/30/12 <br />72 <br />ft