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t <br /> 1 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 3090 Nc%vy -.-a ' r° CmrzIP Stockton, CA, 95206 m <br /> CROSS STREET Navy Dr/W Washington St APN 14-502-019 PARCEL SIZE10.28 a AND USE APPLICATION# Unknown D <br /> v <br /> TOWNER NAME Melanie Rodriguez contact person Gloria Ruiz PHONE (209) 946-0246 ext 8281 <br /> OWNER ADDRESS 2201 W. Washington St CITY/STATE/ZIP Stockton, CA 95219 <br /> CONTRACTOR Gregg Drilling, LLC PHONE (925)313-5800 <br /> CONTRACTOR ADDRESS 950 Howe Road CITY/STATE/ZIP Martinez, CA 94553 <br /> SUBCONTRACTOR Kleinfelder, Inc PHONE (209) 993-2269 <br /> SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 <br /> LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 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 one(1)cone penetrometer test soundings <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings E Geotechnical two(2) #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair PA y� <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well CasingT <br /> WELL CONSTRUCTION ' <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 40 to 60 ft Excavation 2 to 8 in diameter D Open Bottom ❑ Gravel Pack/Gravel Size 1111 d' rttes <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft N'J6 Z <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ O i ,t�r/Vy,CgQdk"4-1 <br /> Grout Seal Depth 40 to 60 ft ■Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement saCk�fts7 <br /> ❑ Bentonite(20%solids) ■Other upto5%bentonite /►f f <br /> Grout Placement Method ■Pumped D Free Fall ■Other Tremie Full-Depth ❑ Retardant/Accelerator(name) T <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 HOUR ADVANCE*NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By L` Date S.?S .Z Area s��k�oh Employee ID# rns <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Date Invoice# Well ID# <br /> Codes Info B Cpsh Remitted I I Service aquest# <br /> 7F D CSR GO ZZ <br /> EHD043-06 04/07!2022 ��/'IC /" y/� ��� �Page I�of2��� Well/Pump Pe,mit <br />