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i WELL/PUMP PERMIT <br />SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN.ML1-UNL1At5LL Yt=RMIT <br />,JOB ADDRESS 16701 W St RL 12 <br />CROSS STREET Bouldin Island <br />GALL (ZUV) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />CrrY/ZIP Stockton, California <br />APN 069-10-001 PARCEL SIZE LAND USE APPLICATION # <br />NAME Metro Water District of Southern California <br />OWNER ADDRESS PO Bix 54153 <br />CONTRACTOR Exploration Geoservices. Inc <br />CONTRACTOR ADDRESS 563 Asbury Street <br />SUBCONTRACTOR Hultgren - Tiflis Engineers <br />SUBCONTRACTOR ADDRESS 4085 Nelson Avenue. Suite A <br />LICENSE 0 C-57 C-61 _ D-09 _ Other <br />PHONE <br />CITY/STATE/ZIP Los Angeles, California 90054 <br />PHONE 408-280-6822 <br />CITY/STATE/ZIP San Jose, California 95110 <br />PHONE 925-685-6300 <br />CITY/STATE/ZIP Concord, California 94520 <br />NUMBER 484288 EXPIRATION DATE 12/31/2023 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />i <br />INTENDED USE Domestic/Private Irrigation/Agricultural _ Industrial Water Quality Monitoring p Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well _i Well Alteration/Modification Other <br />17 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings EIGeotechnical 7 # of borings <br />I Out -Of -Service Well C Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />New rump rump Keplacement a t-ump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method O Mud Rotary Air Rotary 0 Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />.. Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched C Steel C Plastic Stainless Steel Other <br />Grout Seal Depth 50 ft m Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) - Other <br />Grout Placement Method l7 Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick <br />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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By / e_- Date y �� <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection B Z Date y -/.7Ze72.7 <br />COMMENTS <br />Area 6 q Employee ID# j A <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received 0t-4, <br />Constructed Well Depth AF04 A _ i <br />EHDO43-06 10 25 2021 I 1—t U G rX4 1 of6l� %%,'! Pimp P.r�;c <br />4 <br />11,10909 <br />MMORNA <br />EHDO43-06 10 25 2021 I 1—t U G rX4 1 of6l� %%,'! Pimp P.r�;c <br />