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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT /� CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Lao i A (,e Jc- isr> i S � , CITY/ZIP Stockton, CA <br />CROSS STREET E Anderson St APN 15132004 PARCEL SIZE LAND USE APPLICATION # <br />NAME UPRR PHONE <br />OWNER ADDRESS 844 E 5th St lgao p004) (t$ S1. slop 16go cI7Y/STATE/ZIP Stockton, CA 95206 o me we, At <br />CONTRACTOR Kleinfelder <br />PHONE 661-302-2054 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/Zip Stockton, CA 95206 <br />SUBCONTRACTOR Taber Drilling PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP Nest Sacramento, CA 95691 <br />LICENSE A-57 � C-61 -1 D-09 n Other NUMBER 969927 EXPIRATION DATE 2/28/202114 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE Domestic/Private -1 Irrigation/Agricultural F 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 I Replacement Well i I Well Alteration/Modification c Other <br />Monitoring Well(s) # of wells /Soil Boring(S) 2 # of borings ❑ Geotechnical <br /># of borings c <br />' 1 <br />Out -Of -Service Well n Out -Of -Service Well Renewal C Cross -Connection Repair <br />New Pump a Pump Replacement a Pump Repair L Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method /Mud Rotary Air Rotary XAuger n Cable Tool i Push Point -1 Other Q A_ <br />Proposed Well Depth 150 (max) ft Excavation 8 (max) in diameter - Open Bottom F- Gravel Pack/Gravel Size in d el♦ <br />Li Conductor Casing in diameter / Conductor Casing Depth It <br />HFq` Vl <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad =i Steel L Plastic L Stainless Steel <br />7 Other r/ 1 <br />_ <br />Grout Seal Depth 150 (max) ft Neat Cement (941b bag/5-10 gal water) C Sand Cement <br />sack mixl7 gal water <br />n Bentonite (20% solids) Other <br />Grout Placement Method Pumped -1 Free Fall XOther Tremie n Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller n Pump Contractor -1 Other <br />Concrete Pedestal nDimenslons: Width It Length ft Thick <br />in Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersibleii Turbine _I 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 "� /�—�y Date 3 9q eI Area St "G "- Employee ID# <br />Grout Inspection By r ddb Date 2+ ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />N <br />D <br />0 <br />0 <br />m <br />m <br />N <br />N <br />V 91 "79 <br />9 <br />EHDO43-06 1025/2021 <br />Page 1 ort <br />well / Pump Permit <br />