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" \1O L � J � l�' WELUPUMP PERMIT <br />SAI! JoA0UM1 COUNTY ENNRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (208) 468.3420 <br />RVR-RChUKOAE1Lt PILKMIT I:ALL 2V9 903 -/blit FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRess Median of 1-5 along Stockton Deep Water Channel Bridge C"jzIP Stockton, 95203 <br />CROSS STREET est Fremont Street APN r31 <br />r, I OCA! PARCEL SUE LAND USE APPLICATION # <br />OwNER NAME Public Right of Way <br />PHONE <br />OWNER ADDRESS NA <br />CRYISTATEr� <br />CONTRACTOR Kleinfelder <br />PHONE 916-366-1701 <br />CONTRACTOR ADDRESS 2662 Prospect Park Drive <br />CITY/STATE/Zjp Rancho Cordova, CA 95670 <br />SUBCONTRACTOR Pitcher Drilling Co. <br />PHONE (650)328-8910 <br />SUBCONTRACTOR ADDRESS -___„218 Demeter St. <br />Cm/STATE/ZIP Fast Paln Alto- CA 94303 <br />LICENSE 1 C-57 C-61 D-09 Other <br />NUMBER 263085 EXPIRATION DATE 9/30/2019 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic(Private Irrigation/Agricultural Industrial Water Quality Monitoring 4 Soil Sampling/Characterization <br />Public Water System <br />If dilferent horn Wal. em ams CoRad N.- or a wn er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 5 X of oonrN° ” Geotechnical pof boon6 <br />Out -Of -Service Well Out -0f -Service Well Renewal Cross -Connection Repair <br />Drilling Method A Mud Rotary Air Rotary Auger Cable Tcol Post) Point r Other 5 Mud Rotary <br />Proposed Well Depth 200 R Excavation 4 to 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neal Cement (94 lb bag/5-10 gal water) Sand Cement sack m1x17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall E]Other Tremie Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length -__ It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level , <br />1 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. 1 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 />MINI U 4 HOUR ADV 1C_E-NOT CE EQUIRED FOV INSPECTIONS -PLEASE CALL (209 953-7697 <br />SIGNED.. �� «nn% V)Nk,l,r� TITLE t�lu+ t DATE <br />AQt <br />Appfication Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring 1 ion By <br />COMMENTS AI t 14 1AAa <br />or <br />g <br />A <br />,ro'a <br />IENT�fUE O LY l.�r <br />//� <br />pare !/ Areal ✓ Employee 1.1,d"Date SPECIAL Well Perrnit <br />Date WAIVER Received <br />Dale �Contr <br />d W01 Depth <br />vt" ULL.7' 7 ft <br />_J'- ? <br />PE SC Received CheckA4 Amount Permit/ <br />Codes Info 13 Date Cash Remitted Service Request / Invoice 0 Well ID/ <br />EHDl3-08 � - r��S' WELL /PUMP PERMIT <br />EFID���000 <br />