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JOB ADDRESS 2849 East Myrtle Street crrvizip Stockton / 95205 <br /> <br />CROSS STREET N Filbert Street APN 157-020-11 <br /> <br />PARCEL SIZE 10 AC LAND USE APPLICATION # <br />PHONE (209) 943-1111 <br /> <br />San Joaquin Regional Transit District OWNER NAME <br /> <br />OWNER ADDRESS <br />CONTRACTOR <br />421 East Weber Avenue p.o iL). a 0 <br />Taber Drilling <br />Crrv/S-rivre/ZiP Stockton, CA 95202 <br />PHONE 916-371-8234 <br />(14.0.)- <br /> <br />CONTRACTOR ADDRESS 536 Gavleston Street Crrv/STATE/ZIP West Sacramento, CA 95691 <br /> <br />BSK Associates SUBCONTRACTOR <br /> <br />PHONE 925-315-3151 <br /> <br />550 W. Locust Avenue SUBCONTRACTOR ADDRESS <br />Fresno, CA 93650 CCITY/STATE/ZIP, IP <br /> <br />LICENSE x C-57 C-61 D-09 Other <br />NUMBER 969927 <br /> <br />EXPIRATION DATE 2/29/2024 <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />ft Thick <br />Other <br />ft Length MAY 0 2 2022 PEDESTAL Installed By Driller Pump Contractor <br />Concrete Pedestal Dimensions. Width <br />in Christy Box Stove Pipe <br />ft Standin kiNkfAcINVENTAL ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the -orlYoUgt items:rni EPS <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 />virsivit \ I 24 IRA 1,2 \I) \ \ ( 1 \ /IR 1 RI Q11101 I) l{)12 I ION', I'l I \NI0 \i .l (2119) t 7(0)7 <br />ft <br />1 117x f, <br />construec:t Well Depth <br />eigirVi <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> <br />Soil Boring Inspection By <br />COMMENTS 8,Ihtrifl5 ) isir4 resit- <br /> <br />Date <br />iL- Date • 7 2 <br />Date <br />to k ior/ Employee ID# FYI 5) <br />SPECIAL Well Permit <br />WAIVER Received <br />Area <br />Pump Set HP Submersible Turbine Other <br />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 />DOMESTIC WELL SAMPLING: 0 General Mineral/Colifomi Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification x Other 2 CPTs <br /> <br />Monitoring Well(s) # of wells x Soil Boring(s) 1 # of borings Geotechnical it of bonngs <br />Out-Of-Service Well <br />NPW Pump Pumn Reolacement <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pumo Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Grout Placement Method Pumped x Free Fall X Other Tremie <br />Well Casing <br />Grout Seal <br />Depth 10-50 ft Excavation 6-8 in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Depth Jo - tz. ft X Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) Other <br />Mud Rotary Air Rotary x Auger Cable Tool Push Point X Other 2 CPTs <br />Retardant / Accelerator (name) RECEIVED <br />Sand Cement pAymehmai water <br />in diameter <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />iiria i s-o -,- 1317 .31S Cl 1 7o 3 .1 .2-1 W P 00 ,-130S I <br />1,111)043-06 11125 2021 Well rump Permit