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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE- STOCKTON CA 95205 -6232 (209) 466-3420 <br />NON-REFUNDABLE PERMIT www.ojgov.org/0hd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I^I-) ��' I_at: 38.021040". Loo;-121..33116��33676° Cm21P Stockton. CA. 95206 <br />CROSS STREET Mariners Dr/Hammer Ln APNZjEaLjr. 0-7jR��=PARCEL SIZE NIA LAND USE APPLICATION #Unknown <br />OWNER NAME Citv of Stockton Public Right of Way _. _ PHONE 1209) 937-8561 <br />OWNER ADDRESS 345 N. EI Dorado Street CITYISTATE/LPStocktOni CA 95202 <br />CONTRACTOR Gregg Drilling, LLC _ PHONE (925) 313-5800 <br />CONTRACTOR ADDRESS 950 Howe Road CITY/STATEIZIP Martinez, CA 94553 <br />SUBCONTRACTOR/CONSULTANT Kleinfelder, Inc PHONE (559)270-6349 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATEIZIP Stockton, CA 95206 <br />LICENSE 0 C-57 i C-61 D-09 I I Other NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br />BILLING PARTY: OWNER Ii CONTRACTOR N SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromoehloropropane (4392) i Arsenic (4393) <br />INTENDED USE I . Domestic/Privale , Irrigation/Agricultural , Industrial Water Ouslily Monitoring Soil Sampling/Characterization <br />I i Public Water System <br />If daerent from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK % I New Wel 1! Replacement Well I Well Alteration/Modification Other <br />I I Monitoring Well(s) # of wells � Soil Boring(s) a W b°"na' ■ Geotechnical six (6) a of minae <br />i, Out -Of -Service Well I - Out -Of -Service Well Renewal i Cross -Connection Repair <br />Drilling Method Pud Rotary t. Air Rotary I i Auger I I Cable Tool , Push Point I Other <br />Proposed Well Depth 45 it Excavation Wr A - In diameter : I Open Bottom , Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter ! Conductor Casing Depth It <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Sched I Steel I I Plastic I I Stainless Steel 1 ' Other <br />Grout Seal Depth 45 It 0 Neat Cement (941b bag/5-10 gal water) I' Sand Cement sack mix17 gal water <br />: Bentonite (20% solids) 0 Other up to ° bentonite &t 4 Ver r'f, <br />Grout Placement Method N Pumped ' I Free Fall MOther Tremie Full-Den1h Iretardant /Accelerator (name) <br />PEDESTAL Installed By .. Drifter r Pump Contractor Other __ <br />Concrete Pedestal �Dimensions: Width ft Length ft Thick in I I Christy Box ii Stove Pipe <br />PUMP Submersible, Turbine 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 CAI IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE ATION W . <br />MI 48 H U.A�D NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />'T <br />SIGNED TITLE tG=►'11Ci0tf1S DATE <br />SEE ATTACHED BORING LOCATION MAP <br />RFq ytiiE <br />0 <br />08 ?0 <br />NFF"�R Qjji" <br />�FpgR . 44 <br />"r <br />DEPARTMENT USE QNLY <br />Application Accepted By -- Data <br />O ,; Amit _� / j� k4D11 Employee IDiI M <br />Grout Inspection By Data 1: SPECIAL Well Permit <br />Pump Inspection By Date I WAIVER Received <br />---- <br />Soil Boring Inspection Date Constructed Well Depth ft <br />COMMENTS pr-r�tfn C�/1I✓ /)_ '.N�n(�jj�L�YI'61tS <br />PE Sc <br />Codes Into <br />W370-7 IS- <br />Received Check#/ Amount Date <br />Allin Cash I Remitted <br />a <br />Permit/ Invoice # Well IDA! <br />S rviCeRe ue t# _ <br />ElID 4J -0e B/IlRe/a <br />WFI I M4IMP PFRMIT <br />