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1� WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5070 Promontory Parkway CITY/ZIP Tracy, CA 95377 <br />CROSS STREET Promontory Pkwy and N Handsen Rd APN 20922028 PARCEL SIZE 208.41 LAND USE APPLICATION # <br />OWNER NAME Prologis LP PHONE 510-661-4028 <br />OWNER ADDRESS 3353 Gateway Blvd CITYISTATE/ZIP Fremont, CA 94538 <br />CONTRACTOR Kleinfelder PHONE 661-302-2054 <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 <br />SUBCONTRACTOR Taber Drilling <br />SUBCONTRACTOR ADDRESS 536 Galveston St <br />LICENSE / C-57 C-61 D-09 Other <br />CITY/STATE/ZIP 95206 <br />PHONE 916-371-8234 <br />CITY/STATE/ZIP West Sacramento, CA 95691 <br />NUMBER 969927 <br />EXPIRATION DATE 2/292024 <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 <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 8 # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br />Proposed Well Depth 30 (max) ft Excavation 8 max 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 30 (max) ft / Neat Cement (941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Tremie Retardant / Accelerator (name) <br />"EDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />n Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />�NlININILiNI 24 IIOLR ADVA\Ch: NO'l R F REQt IRED FOR INSPIX MONS - PI F kSF: CALL., (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By —� Date �y c,Z Area s %!s% r Employee ID# � �. <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTSX � ,, Yz�ib bP C&n t,' `� F'� 14) PC) 0 Lia 613 <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />EHDO43-06 10/25/2021 Page 1 of 2 well / Pump Permit <br />