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f <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS 0 Chu r <br />CROSS STREET S Union St <br />OWNER NAME UPRR <br />GALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton, CA 95203 <br />APN 15126036 PARCEL SIZE LAND USE APPLICATION # <br />PHONE <br />OWNER ADDRESS 844 E 5th St Igad DOJO$ S/ 9 b CITY/STATE/ZIP Stockton, CA 95206 OmLihA, Ni <br />CONTRACTOR Kleinfelder PHONE 661-302-2054 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CIN/STATE/ZIP Stockton, CA 95206 <br />SUBCONTRACTOR Taber Drilling PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St CRY/STATE/ZIP West Sacramento, CA 95691 <br />LICENSE A-57 C-61 7 D-09 fl Other NUMBER 969927 EXPIRATION DATE 2/28/202 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE n Domestic/Private -1 Irrigation/Agricultural r Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK U New Well u Replacement Well U Well Alteration/Modification L Other <br />L, MonitoringWell(s) #of wells /SoilBoring(s) 1 #of borings U Geotechnical #of borings <br />D Out -Of -Service Well D Out -Of -Service Well Renewal C Cross -Connection Repair <br />D New Hump L1 Pump Ke lacement LI vurnp Ke air L Kalse vveu i.asm <br />WELL CONSTRUCTION <br />Drilling Method XMud Rotary F Air Rotary XAuger R Cable Tool F Push Point -� Other <br />Proposed Well Depth 50 (max) ft Excavation 8 (max) in diameter -1 Open Bottom L Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 7 Steel D Plastic Stainless Steel 7 Other <br />Grout Seal Depth 50 (max) ft / Neat Cement (94 lb bagl5-10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite (20% solids) n Other <br />Grout Placement Method Pumped 7 Free Fall Other Tremie n Retardant / Accelerator (name) <br />PEDESTAL Installed By � Driller n Pump Contractor -1 Other <br />f� Concrete Pedestal 'Dimensions: Width ft Length ft Thick <br />in -.1 Christy Box U Stove Pipe <br />PUMP D SubmersibleD Turbine _1 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 />MINIMUNI 24 HOUR ADVANCE NOTTCE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />I DEPARTMENT USE ONLY A <br />Application Accepted By [� Date _ u% / Area Sf�ik� Employee ID# 1 �I _ <br />Grout Inspection By �'I�L—a..� Date ZZ ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS e Sf/i 2stl 9�� sf�'=9 u�� �� 6��-7G Z .� 6 44Lf <br />rn <br />m <br />g <br />0 <br />z <br />m <br />N <br />N <br />680 q <br />12022 <br />Well / Pump Permit <br />