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1� WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 12091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOBADDRESS 5070 Promontory Parkway CITY/ZIP Tracy, 95377 CROSS STREET Promontory Parkway and N Hansen Road APN 20922028 PARCEL SIZE 209.41 Acres LAND USE APPLICATION # OWNER NAME Prolo is LP PHONE 510-661-4028 OWNER ADDRESS 3353 Gateway Blvd — 64) S�itle 5V Z0UCITY/STATE/ZIP Fremont, Ca 94538 CONTRACTOR Kleinfelder PHONE 661-302-2054 CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 CITY/STATE/ZIP Stockton, CA, 95206 SUBCONTRACTOR Geo -Ex Subsurface Exploration PHONE 916-799-8198 SUBCONTRACTOR ADDRESS 1510 Madera Drive CITY/STATE/ZIP Dixon, CA,_95620 LICENSE C-57 C-61 ❑ D-09 Other NUMBER 954267 EXPIRATION DATE 07/31/2022 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Private - Irrigation/Agricultural ii Industrial Water Quality Monitoring Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification -� Other Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings^ Out -Of -Service Well Out -Of -Service Well Renewal =i Cross -Connection Repair A Y New Pump ❑ Pump Replacement i Pump Repair ❑ Raise Well Casing vkhq Z WELL CONSTRUCTION Drilling Method Mud Rotary ❑ Air Rotary Auger n Cable Tool -..i Push Point -i Other IJAP Proposed Well Depth 5-30 ft Excavation 6-8 in in diameter i Open Bottom Gravel Pack/Gravel Size 'iniflia6ierm Conductor Casing in diameter / Conductor Casing Depth ft Jpq Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Otl A, - Qu//v Grout Seal Depth 5-30 ft / Neat Cement (94 lb bag/5-10 gal water) _ Sand Cement sackf 6 Bentonite (20% solids) Other RT Grout Placement Method /Pumped Free Fall r i Other Retardant / Accelerator (name) PEDESTAL Installed By r Driller _i Pump Contractor Other Concrete Pedestal Dimensions: Width ft Length ft Thick �in -i Christy Box Stove Pipe PUMP ❑ Submersible❑ Turbine Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 DEPARTMENT USE ONLY n Application Accepted By `�� Date ► as Area CV Employee ID# AS Grout Inspection By Date Z ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS rg by A inIDA e►- 0 ( m D v v M m CO) a)b9i Nry NT 36 PE Codes SC Received Check#/ Info Cash Amount Permit/ Date Invoice # Well ID# Remitted Service Request # F.HD043-0610/25,202I�� /) �/� / �C/ �P/ U f� Well; Pump Permit IOf2a,;�1� A,5t; 111140,