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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABI F PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Jos ADDRESS ooa ., (: 'Isv�? CITY/ZIP Stockton, CA <br />CROSS STREET E Jackson St APN 15134002 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME UPRR PHONE <br />OWNER ADDRESS 844 E 5th St / f oQ Dcxr `1 -, .s SI Sirw / CqD CITY/STATERIP Stockton, CA 95206 OM461 N <br />r <br />CONTRACTOR Kleinfelder 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 West Sacramento, CA 95691 <br />LICENSE C-57 -i C-61 -i D-09 n Other NUMBER 969927 EXPIRATIONDATE 2/28/2041 <br />DOMEsnc WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE n Domestic/Private - Irrigation/Agricultural r- Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK u New Well L Replacement Well U Well Alteration/Modification Other CPT <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical 2 CPT # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal C Cross -Connection Repair <br />New Pum -i Pump Replacement U Pump Repair L Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I Mud Rotary F Air Rotary 7 Auger n Cable Tool F Push Point / Other Direct Push <br />Proposed Well Depth 130 (max) ft Excavation 4 (max) in diameter -1 Open Bottom F- Gravel Pack/Gravel Size in dia <br />Conductor Casing in diameter I Conductor Casing Depth ft NE.4 <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched -1 Steel C Plastic L Stainless Steel L Other <br />Grout Seal Depth 130 (max) ft / Neat Cement (94 Ib bag/5-10 gal water) C Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) n Other <br />Grout Placement Method - Pumped Free Fall XOther Tremie F] Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller n Pump Contractor -1 Other <br />n Concrete Pedestal nDlmensions: Width ft Length ft Thick <br />�in U Christy Box U Stove Pipe <br />PUMP ❑ Submersibleo Turbine -3 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 />�p + DEPARTMENT USE ONLY I ) <br />Application Accepted ByDate aArea 51�X1c-��J� Employee ID#�� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection ByDate Constructed Well Depth it <br />COMMENTS zy�- \1 <br />LA <br />I <br />a <br />0 <br />0 <br />A <br />m <br />w <br />w <br />1907�I <br />EHDO43-06 10/25/2021 Page I oft <br />well / Pump Permit <br />