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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE <br />NON-REFUNDABLE PERMIT <br />- STOCKTON CA 95205 .6272 (209) 468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS 0 N c:lel ►M �' <br />38 021040°. Lgg: -121.363676° cnylzjP Stockton CA. 95206 <br />CROSS STREET Mariners Dr/Hammer Ln <br />APN 0 771-130-180 PAR{111 <br />LAND USE APPLICATION A Unknown <br />OWNER NAME Tyler Kelley l�ati Vr k� <br />dgy L.CELSEEf <br />ffoppiibes LLG ti? <br />PHONE (209)477-1207 <br />OwNii( ADDRESS 9099 Mariners Drive <br />GTy/STATERIP <br />Stockton, CA 95219 <br />CONTRACTOR Gregg Drilling, LLC <br />PHONE (925) 313-5800 <br />CONTRACTOR ADDRESS 950 Howe Road <br />Cm'/STATE/LP Martinez, CA 94553 <br />SUBCONTRACTOR/CONSULTANT Kleinfelder, Inc <br />PHONE (209) 993-2269 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/7JP <br />Stockton, CA 95206 <br />LICENSE E C-57 1 1 C-61 I I D-09 <br />11 Other NUMBER 1044456 <br />EXPIRATION DATE 09/30/2022 <br />BILLING PARTY: I i OWNER <br />'I CONTRACTOR 0 SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: ; I General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE I : DomeslidPrivale Irrigation/Agricultural : Industrial Water Quality Monitoring a Soil Sampling/Characterization <br />I I Public Water System_ _- <br />- —-- --- <br />If different from Owner: Waley System Name Contact Name or Phone Number <br />TymOF WcRK ; I New Well 1! Replacement Well 1 Well Alteration/Modification 0 Other one (1) cone penetrometer test sounding <br />I 1 Monitoring Well(s) A of wells , Soil Borings) ° oI bunnga ■ Geotechnical rive (5) a or borings <br />I Out -Of -Service Well Out -Of -Service Well Renewal 1 . Cross -Connection Repair <br />New Pump Pun p Replace Ttrnl rump RepairRaise Well CaanQ <br />jDrllling Method 1 Mud Rotary - 1 Air Rotary 1 Auger ' 1 Cable Tool 1 Push Point I I Other <br />)Proposed Well Depth 55 to 80 It Excavation 2 to 8 in diameter I . Open Bottom I I Gravel PecklGravel Size in diameter <br />I i Conductor Casing In diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 1 1 Steel I Plastic I I Stainless Steel ' i Other _ <br />Grout Seal Depth 55 to 80 ft 0 Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement sack mixR gal water <br />i , Bentonite (20% solids) a 0!her u lc 541s h-ntorlite <br />Grout Placement Method 0 Pumped i Free Fall III Other Tra Full- De lh I i Retardant /Accelerator (name) <br />'PEDESTAL Installed By _ Dnller 1, Pump Contractor 11 Other <br />Concrete Pedestal iDimensionr. Width ft Length ftThick in , Christy Box Stove Plpe <br />PUMP I Submersible) � Turbine ' . Other HP Pump Set ft StandlnG Water Level ft I <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 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />MIVIIIIIJ& 464-IOX)RhADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SEE ATTACHED BORING LOCATION MAP <br />DEPARTMENT USE ONLY <br />Application Accepted By_ LL Date 2 O>3 I'1 <br />Grout Inspection By � F /^� Dale 2"% <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />DATE <br />3s toe R-1-0 �1 kArca Employee IDA <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />RE YM� <br />�41 <br />QFC <br />0820 <br />4 Q(jl 21 <br />PqR ��NTy <br />PE SC Received <br />Codes Info <br />Check#f rmill Invoice M Well IDM <br />Cas Remitted Wee Re uestM <br />L43-7,07 o <br />_ <br />nt <br />EMD 43.06 0/112019 WELL /PUMP PERMIT <br />