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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />JOB ADDRESS 3121 Monte Diablo Ave CrTYmP Stockton, CA 95203 <br />CROSS STREET Shimizu Dr APN 13306012 PARCEL SIZE2 5 • 9 6 LAND USE APPLICATION # <br />OWNER NAME City Of Stockton PHONE <br />OWNER ADDRESS 425 N El Dorado St CITY/STATEILP Stockton, CA 95202 <br />CONTRACTOR ConeTec, Inc. PHONE 510-357-3677 <br />CONTRACTOR ADDRESS 820 Aladdin Ave Cmr/STATEILP San Leandro, CA 94577 <br />SUBCONTRACTOR/CONSULTANT Kleinfelder PHONE 661-302-2054 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATEILP Stockton, CA 95206 <br />LICENSE /C-57 C-61 D-09 Other NUMBER 1049248 ExPIRATIONDATE 1/31/2023 <br />BILLING PARTY: OWNER CONTRACTOR UBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wellsSoil Boring(s) 4 CPT S # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />ISSUED <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point /Other CPT ( direct push) <br />Proposed Well Depth 60 ft Excavation 2 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 6 0 ft Meat Cement (941b bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other tr emi e Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Widthft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft 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 />MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED IL �L'Bi%LQ.GU' TITLE Operations Manager DATE 11/30/2021 <br />RF �MF,y <br />�0 03 <br />.q QUlYO/V 00 <br />?0?1 <br />See Attached Map <br />DEPARTMENT USE ONLY <br />Application Accepted By 'Z=L L Date <br />Grout Inspection ByDate <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area i S }Oe Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EM U1701 VIK�XA«_j6M11F�Iwri10AljiPrd <br />wit � <br />EHD 4306 6111/1019 �l --:e <br />: /35- <br />4167 <br />'y � WELL /PUMP PERMIT <br />