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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-KEFUNDABLE PERMIT GALL (ZU9) 9b3 -/b9/ FOR INSPECTIONS tAVIKtb "I YEAR FROM DATE ISSUED <br />JOB ADDRESS 0 Interstate 5 at Postmiles 38.41 and 41.07 CITY/ZIP Lodi 95242 <br />CROSS STREET 5100- 1L6V}e APN oa5 11 Z)0 nev:C ARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME California Department of Transportation PHONE <br />OWNER ADDRESS 1801 30th St CITY/STATE/ZIP Sacramento, CA 95816 <br />Gregg Drilling, LLC - Laura Gregg PHONE (714) 337-9726 <br />ADDRESS 950 Howe Rd CITY/STATE/ZIP Martinez, CA 94553 <br />ADDRESS <br />LICENSE x C-57 C-61 D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 1044456 EXPIRATION DATE / <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring x 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 Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) # of borings x Geotechnical 2 # of boring&�* Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair New Pump Pump Replacement Pump Repair Raise Well Casing <br />Drilling Method x Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 -ft ft Excavation 4.5 -in in diameter Open Bottom Gravel Pack/Gravel Size S <br />Conductor Casing in diameter / Conductor Casing Depth ft 4r. <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel <br />Grout Seal Depth 50 -ft ft x Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method x 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 />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 />h1ININIUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />/ DEPARTMENT USE ONLY <br />Application Accepted By �'�- Z --L' Date 3i.2'� <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Area �� Employee ID#�li <br />SPECIAL Well Permit <br />WAIVER Received <br />Date y - 1e 2/y Constructed Well Depth <br />ft <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />PE SC Received <br />Codes Info <br />a rso <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted S ce e t # <br />4 4 <br />0 <br />EHDO43-06 10/25/2021 Page I of 2 Well / Pump Pemik <br />