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M I ' WELL/PUMP PERMIT SAN ,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 ttivttl-RGrUtvUHtsLG 6 tKtvll l .JOB ADDRESS 1221 S Bacon Island Road CROSS STREET Bacon Island OWNER NAME Metro Water District of Southern California OWNER ADDRESS PO Bix 54153 %,ALL TOR Exploration Geoservices. Inc, CONTRACTOR ADDRESS 563 Asbury Street UbJ-IbUl FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED CITY21P Stockton. California APN 129-05-018 PARCEL SIZE LAND USE APPLICATION # PHONE CRY/STATE/ZIP Los Angeles, California 90054 SUBCONTRACTOR Hultgren - Tillis Engineers SUBCONTRACTOR ADDRESS 4085 Nelson Avenue, Suite A LICENSE O C-57 U C-61 D-09 Other PHONE 408-280-6822 CITYISTATE/ZIP San Jose. California 95110 PHONE 925-685-6300 CITYISTATE/ZIP Concord, California 94520 NUMBER 484288 EXPIRATION DATE 12/31/2023 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE -1 Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner Water System Name Contact Name or Phone Number I YPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification IOther ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 0 Geotechnical 4 # of borings ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal U Cross -Connection Repair New Pump Pump Replacement ❑ Pumo Repair n Raise Walt rasinn Drilling Method ❑ Mud Rotary Air Rotary El Auger Cable Tool Push Point Other Proposed Well Depth 50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other Grout Seal Depth 50 ft m Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water Bentonite (20% solids) Other Grout Placement Method I] Pumped Free Fall Other Retardant / Accelerator (name) PEDESTAL Installed By Driller L Pump Contractor Other - Concrete Pedestal FDimensions: Width ft Length ft Thick in 0 Christy Box Stove Pipe PUMP ❑ Submersible Turbine Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MIINIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY i n Application Accepted By T7 l Date 3 ` "7 Area -� �j C Employee ID# Grout Inspection By Date ❑ SPECIAL Well Per t Pump Inspection By Date ❑ WAIVER Receive Soil Boring Inspection By Date Constructed Well Depth ;C1 �R COMMENTS S%i�fY� /�;� f>156 Iv:�)f�tl� G;/ s<.�L"! 1 142 101, HIAA PE I SC Received Check#/ Codes Info B Cash Amount ®ate Remitted Permit/Invoic 'Y v Service Re uest# E 01y/N�9� # X31,2 IS0 Y' 4 v' 3 22 3u P A EHD043-06 10'_5 ZO? I '1 � �}' � 111. ( ) `d IVIVIyf J —T �/ ✓_lJ ✓ `,J� - iV:fl ^cmp P.rmit T 1 M D v v M M rA rn