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I WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENT L HEALTH DEPARTMENT 1868 EAST H ZELTON AVENUE -STOCKTON CA 95205 - (209) 466-3420 NUN-KEFUNDABLE PERMIT CALL LUy 9b.5 -/by/ FOR INSPECTIONS t:Al'lKtb 7 YEAR FROM U TE ISSUED JOB ADDRESS 10;& H c' -z 4-a ri CITY21PStockton, CA 92505 CROSS STREET S[�Union St APN 15128036 PARCEL PARCEL SIZE 113 ) LAND USE APPLICATION # OWNER NAME Aria N'1' k and �I wal Gl ^ � � �C4 %� PHONE OWNER ADDRESS (_l �� L . `II1��G! leCITY/$TATE/ZIP S 1�Wyk, "k, f Q CONTRACTOR Kleinfelder PHONE 661-302-2054 CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 SUBCONTRACTOR Taber Drilling PHONE 916-371-8234 SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacramento, CA 95691 LICENSE A-57 -i C-61 -1 D-09 7 Other NUMBER 969927 EXPIRA11ONDATE 2/28/202 DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) INTENDED USE DOmestiC/Private -1 Irrigation/Agricultural - Industrial - Water Quality Monitoring Soil Sampling/Characterization Li Public Water System -141 If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK L1 New Well L Replacement Well l l Well Alteration/Modification /Other CPT D Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical 1 CPT # of borings D Out -Of -Service Well Out -Of -Service Well Renewal C Cross -Connection Repair _ '7 Drilling Method r-1 Mud Rotary n Air Rotary � Auger n Cable Tool I- Push Point / Other Direct Push Proposed Well Depth 100 (max) ft Excavation 4 (max) in diameter Open Bottom n Gravel Pack/Gravel Size in diame i Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Schad Steel ❑ Plastic ❑ Stainless Steel - Other Grout Seal Depth 100 (max) ft / Neat Cement (94 lb bagl5-10 gal water) C Sand Cement sack mW7 gal water I 1 Bentonite (20% solids) F1 Other Grout Placement Method I Pumped Free Fall XOther Tremie n Retardant / Accelerator (name) )EDESTAL Installed By n Driller n Pump Contractor -1 Other FI Concrete Pedestal nDimensions: Width ft Length ft Thick n u Christy Box u Stove Pipe PUMP D Submersible❑ Turbine :i Other HP Pump Set ft Standing Water Level ft Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPFCTIONS - PLEASE CALL (209) 953-7697 j J DEPARTMENT USE ONLY l y Application Accepted By/ul�� Date Area TJG�iD%IEmployeeID#�,� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ' ❑ WAIVER Received Soil Boring Ins action By Date 3 - Z� Constructed Well Depth ft COMMENTS .% eat CGV IIM-SP1/r:JI .� HIM"'3' HDO43-0610/2 202 age oft W :i�- 14673z49 7 Well / ..Pp. -it r RTM..