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WELL/PUMP PERMIT <br />SAN JOAOUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE- STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Median of 1-5 along Stockton Deep Water Channel Bridge crTyrbp Stockton, 95203 <br />CROSS STREET West Fremont Street APNIllAr) � %oi 0 � ! PARCEL SIZE LAND Use APPLICATION ik_ _ <br />OWNER NAME Public Right of Way PHONE <br />OWNER ADDRESS NA CrtvISTATE/ZIP <br />1pCONTRACTOR Weinfelder PHONE 916-366-1701 <br />/ CONTRACTOR ADDRESS 2882 Prospect Park Drive CTTYISTATE/Zlp Rancho Cordova, CA 95670 <br />SUCCUNTRACTOH Gregg Drilling & Testing Inc PHONE 925-313-5800 <br />SUaCOhTHACTORAD.Eas 950 Howe Rd CIrY/STATE/ZIP Martinez. CA 94553 <br />LICENSE 4 C-57 C-61 D-09 Other NUMBER 485165 ExMAnONIDATE 1/31/2018 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE Domestir/Prlvate Irrigation/Agricultural Industrial Water Quality Monitoring 4 Soil Sampling/Characterizatlon <br />Public Water System <br />Ir di"erenl from Ovmer: V1TnTmNnme--CpnTdTlLrmo ri�'Fnno Aurmm <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Wallis) s of wells Sol] Boring(s) N of eorkve 4 Geotechnlcg-&---q Mof bodrge <br />Out -0f -Service Well Out -Of -Service Well Renewal Cross -Connection Repair IF <br />filling Method 4 Mud Rutery Air Rotary Auyer Cable Tuol Push Point 4 Olher 's -r s S&,S_ <br />,oposed Well Depth 1509*29L Excavation 2 In diameter Open Bottom Gravel PacklGravel Size In diameter <br />Conductor Casing In diameter / Conductor Casing Depth _ n <br />Wall Casing Diameter _ in Thicknesses/�G�auge/ASTM Sched Steel Plastic Stainless Steel Other <br />(trout Seal Depth it %Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water) <br />Bentonite (20% solids) Other <br />rout Placement Method Pumped Free Fall Q Other Trenlie Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length it Thick in Christy Box Stove Plpe <br />PUMP Submersible Turbine Other HP Pump Set It Standing Water Level <br />I HEREBY CERTIFY THAT 1 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 COMPENSATION LAWS. <br />IN OUR NOTICE REQUIRED FOR INS�PEE�rgTTIIONS`-/PLEASE CALL (209) 953-7697 '} <br />SIGNED I J ` C -W/�V�f.S ''•'4 DATE <br />E,P RTMENT U E O �LJY <br />Application Accepted By40 -- -_ - Date <br />Grout Inspection By Date !! <br />Pump Inspection By <br />Soil Boring Inspection By _ Date <br />COMMENTS <br />D <br />°o <br />w <br />i RF���FNT <br />4 <br />OFoMcc�,O� <br />ear�44 1)} <br />4l <br />Area 1ZS11ECIA1 <br />Employee IDtF� Well Permit <br />WAIVER Received <br />Constructed Well Depth _ —n <br />PE Sc Received <br />Codes it" B <br />Checks/ Amount Permit/ <br />Cash Remitted Date Service Ra stir Invoice* Well 10* <br />Cjo <br />l <br />EMD 43-M <br />4=12 <br />WEI 17PlIMn Pr RM;T <br />