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t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> i NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS Caltrans right of way, Interstate 5 CIrY/LP Post Miles 44 .32 & 48.97 m <br /> TK-f/ fL�Y�_ <br /> Caltrans ROW o <br /> CROSS STREE APN PARCEL SIZE NA LAND USE APPLICATION# z <br /> m <br /> rn <br /> OWNER NAME Caltrans PHONE <br /> OWNER ADDRESS 5900 Folsom Blvd CITY/STATEMP Sacramento, CA 95819 <br /> CONTRACTOR Kleinfelder PHONE (916) 366-1701 <br /> 2882 Prospect Park Dr, Ste 200 Rancho Cordova CA 95662 <br /> CONTRACTOR ADDRESS CITYISTATE/LP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE x C-57 J C-61 j D-09 LI Other NUMBER 467252 EXPIRATION DATE 1.21 oILuO <br /> BILLING PARTY: ❑OMNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private J Irrigation/Agricultural J Industrial ,Water Quality Monitoring J Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner. Water System Name Contact Name w Phone Number <br /> TYPE OF WORK C New Well J Replacement Well L Well AReration/Modihcation 7 Other <br /> Monitoring Wells) #of wells ' Soil Boring(s) t of borings X Geotechnical 2 a of borings <br /> I Out-Of-Service Well O Out-Of-Service Well Renewal Cross-Connection Repair <br /> I New Pump U Pump Replacement 0 Pump Repair J Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary J Air Rotary X Auger J Cable Tool Push Point J Other <br /> Proposed Well Depth 3 0 it Excavation 6 in diameter L Open Bottom J Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched J Steel 11 Plastic I_I Stainless Steel J Other <br /> Grout Seal Depth ft I i Neat Cement(94 Ib bag/S10 gal wafer) J Sand Cement sack mix/7 gal water <br /> J Bentonite(20%solids) r Other <br /> Grout Placement Method 8 Pumped '_i Free Fall J Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1.1 Driller t.,Pump Contractor ::I Other <br /> 1 Concrete Pedestal I,,Dimensions:Width It Length ft Thick in :3 Christy Box ❑ Stove Pipe <br /> PUMP J Submersible)Turbine L Other HP Pump Set It Standing Water Level ft <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. 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 /> MINIMUM 48 OU DV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLES/' DATE <br /> T <br /> ILAJ <br /> / C <br /> N <br /> ELL L <br /> DEPARTMENT USE N L Y <br /> Application Accepted By �� Date v �'—I T Area Employee ID# <br /> Grout Inspection By Date ❑ PE tftLW.lI Permit <br /> Pump Inspection By Date J WAIVER Received <br /> Soil Boring Inspection By ( , �" Date l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ChecAmount Date Permd/ Invoice# Well ID# <br /> Codes Info B O Cash h Remi Service Request# <br /> ^I i <br /> EHD 43-06 6/112019 : I O{"--�.�../ �/ `-� � WELL(PUMP PERMIT <br />