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1 <br /> • 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.s(,gov.org/olid _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 170 D 38.021040".Lac:-121.363676' cnyop Stockton.CA.95206 <br /> CROSS STREET Mariners Dr/Hammer Ln APN 071-130-210 PARCELS= 3.0 LAND USE APPLICATIONS Unknown <br /> ig <br /> OWNER NAME Tyler Kelley/ Sotnh Kelley PI VVr Ors PHONE(209)477-1207 <br /> OWNER ADDRESS 9099 Mariners Drive176 07 Park) 3W,k DC c rvlsTATEIZIP Stockton,CA 95219 5-207 <br /> CONTRACTOR Gregg Drilling,LLC PHONE (925)313-5800 _ <br /> CONTRACTOR ADDRESS 950 Howe Road cITY/STATEl2'JP Martinez,CA 94553 <br /> SUBCONTRACTOR/CONSULTANT Kleinfelder,Inc PHONE (209)993-2269 <br /> SUBCONTRACTOR/CONSuLTANTADORESa 2001 Arch Airport Rd,.Suite 100 CITYISTATE/ZIP Stockton,CA 95206 <br /> LICENSE M C-57 ,I C-61 :I D-09 1!Other NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br /> BILLING PARTY: I I OWNER :I CONTRACTOR 0 SUSCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392),;Arsenic(4393) <br /> INTENDItD UaE Domesllc/Private I Irrigation/Agricultural I I Industrial 1,Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> 11 different from Ov r. Water system Name Cor4ed Name or Phone Number <br /> TYPE OF WORK ,I New Well I I Replacement Well I Well Alteration/Modification E Other three(3)cone penetrometer lest soundings <br /> I I Monitoring Well(s) #of wells f:Soil Boring(s) a°I 6a nge a Geotechnical nine(9) •Dr boringa <br /> I•Out-Of-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> I I New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i i Mud Rotary I I Air Rotary I Auger 1 i Cable Tool t Push Point t Other <br /> Proposed Well Depth 55 to 100 R Excavation 2 to B In diameter 1-Open Bottom I Gravel Pack/Gravel Size In diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 1•Steel i,Plastic I,Stainless Steel I Other <br /> Grout Seal Depth 55 to 100 ft a Neat Cement(941b bag/5-10 gal wafer) 1 Sand Cement sack mix!/gal water <br /> Bentonite(20%solids) N Other p to 5 Yo bentonite <br /> Orout Placement Method E Pumped I 1 Free Fall 0 OtherTromie IF I.Death !I Retardant/Accelerator(rienio) <br /> PEDESTAL Installed By Driller Pump Contractor I I Other <br /> Concrete Pedestal Dimensions:Width R Length R Thick _ In Christy Box Stove Pipe <br /> PUMP Submerslblel Turbiner Other HP Pump Set R Standing Water Level It <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 NSA-ON Lf W <br /> MI 1 �M 48 O OR DVANCE NOTICE REQUIRED FOR INSP CTtONS-PLEASE CALL(209)953-76 7 <br /> SIGNED TITLE I DATE <br /> F��T <br /> `CEO <br /> 08 <br /> SEE ATTACHED BORING LOCATION MAP SAN✓p 242 <br /> ENV/AQ /N CO <br /> RT4L Y <br /> Nr <br /> DEPARTMENT USE NLY <br /> Application Accepted By Dale i� 0 Nee 3 Employee Ill <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ChscliFJ Amount Date Permlt/ invoice# Well IDM <br /> Codes Info Ca Remitted $ rvi a Re nest M <br /> d ISO <br /> END 77 Da 0111R010 WELL/PUMP PERMIT <br />