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r <br />I 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 S 07 0 Promontory Parkway CITY/ZIP Tracy, 95377 <br />CROSS STREET Promontory Parkway and N Hansen Road <br />OWNER NAME <br />ER ADDRESS <br />APN 20922028 PARCEL SIZE 211.41 Acres LAND USE APPLICATION # <br />Prologis LP PHONE 510-661-4028 <br />3353 Gateway Blvd - (o Si,,.ie S1. <br />CONTRACTOR Kleinfelder <br />CONTRACTOR ADDRESS 2001 Arch Airport Road, Suite 100 <br />CITY/STATE/ZIP Fremont, Ca 94538 pJJSc -V, <br />PHONE 661-302-2054 <br />CITY/STATE/ZIP Stockton, CA, 95206 <br />SUBCONTRACTOR Geo -Ex Subsurface Exploration PHONE 916-799-8198 <br />SUBCONTRACTOR ADDRESS 1510 Madera Drive CITY/STATE/ZIP Dixon, CA _95620 <br />LICENSE /C-57 C-61 D-09 Other NUMBER 954267 EXPIRATION DATE 07/31/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural 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 Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings �/! Geotechnical 25 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair /� <br />New PumD PumPg <br />Pump Replacement PumD ReDair Raise Well Casing Y/I/►„- <br />!r <br />m <br />D <br />0 <br />O <br />m <br />m <br />Cn <br />rn <br />WELL CONSTRUCTION C^ 11Z T <br />Drilling Method Mud Rotary Air Rotary / Auger Cable Tool Push Point Other C <br />Proposed Well Depth 5-30 ft Excavation 6-8 in in diameter Open Bottom Gravel Pack/Gravel Size���1r �il i meter <br />Conductor Casing in diameter / Conductor Casing Depth ft 202 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel rJ <br />Grout Seal Depth 5-30 ft /Neat Cement (94 lb bag/5-10 gal water) Sand Cement dht I�i(31t�r Y <br />Bentonite (20% solids) Other I H �E NrAL <br />Grout Placement Method /Pumped Free Fall Other Retardant / Accelerator (name) E <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 />MINIMUM 24 fIOUR ADX"ANCt: NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By 1'' �i Date )IJ/.0- <br />Grout Inspection By . Date - <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area SITIe.-C y Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />A <br />ft <br />PE <br />Codes <br />Sc Received Check#/ <br />Info B Cash <br />Amount Dae Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />)Sb <br />F.HD043-06 10 252021 � n n � /�� � Page ��f�/� Well Pump Pennir <br />Zi I <br />