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vi u. _ WELUPUMP PERMIT lPiLl't SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZEI.TON AVENUE-STOCKTON CA 98208-(209)468-0420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED N JOB ADDRESS Staten Island Cm•21p Staten Island D CROSS STREET N.Staten[eland Rd 6 W Walnut Grove Rd APN 069-02-019PARCEL SIZE`r f IIJWD Use APPLICATION# p OWNER NAME Reclamation District 38 PHONE 918-441.6a50 OWNER ADDRESS cJo Wagner 6 Bonslgnore,2151 River Plaza Drive,suite 100 CITY/STATEZP Sacramento,California 95833 CONTRACTORHultgren-Tins.Engineers PHONE 9253854300 CONTRACTOR ADDRESS 4085 Nelson Avenue,Suite A Cm•/STATE/Zjp Concord,CatHomla 94520 SUBCONTRACTOR Gran Driving and Testing PSE 925.3133800 SUBCONTRACTOR ADDRESS 950 Howe Road CITY/STATE21P Martinez,Calllomla 94553 LICENSE r C-57 0 C-81 0 D-09 C Other NUMBER 10�� EMRATION DATE 09/3072020 Domesrlc WELL SAMPLING:❑General Mineral/Col'tform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) INTENDED USE ❑Domestic/Private 0 Irtigation/Agricultural 0 Industrial ❑Water Quality Monitoring v Soil Sampling/Characterization 0 Public Water System If dHierarx fan ovmer: Water System Name Coned Hama or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificatlon r Other 13 CPTe ❑Monitoring Well(s) #of wells ❑Soil Boring(s) 0 o twrhtgs a Geotechnical 4 adburtrps ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method -Mud Rotary ❑Air Rotary ❑Auger 0 Cable Tool 0 Push Point El Other HdlowStem and CPT Proposed Well Depth ^ ft Excavation in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size In diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter t• in Thickness/Gauge/ASTM Schad ClSteel ❑Plastic O Stainless Sleel C Other Grout Seal Dep 11 L ft(C'+Neat Cement(941b bag/3-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator name jEM2Ljj& installed By ❑Driller ❑Pump Contractor 13Other Concrete Pedestal❑Dlmenslons:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe 1ESULP ❑Submersible Turbine 0 Other HP Pump Set ft Standing Water Level ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIO WS. MINIMUM 48 l R E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED Joe Heavin (, TITLE Senor Engineer DATE 05/2012019 / E"R7MENT US ONLY } Application Accepted By J ` � 1 Date r �''�I Area ( C C� Employee Grout Inspection By,/' Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring I ctio y Date Constructed Wall Depth R CCi ME - ( �t• «y, L. -eqn -, PE SC Received Chockll/ Amount Date Pormh/ Invoice# Well IDN Codes Info By Cash Remitted Service.Request I "L' ltid I Csv" Lr EHo 4soe r-id 4/14113 WELL PUMP PERMIT