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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 A700 Wpsl 11 IDIA g �l g@°, -19U&4.9� CITY/ZIP Stockton, CA, 95206 0 <br /> CROSS STREET Navy Dr/Forrestal Village APN 14-503-011 PARCEL SIZE52.52 acrLAND USE APPLICATION# Unknown g <br /> rn <br /> OWNER NAME Melanie Rodriguez contact person: Gloria Ruiz PHONE (209) 946-0246 ext 8281 �? <br /> OWNER ADDRESS 2201 W. Washington St CITYISTATE/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 N 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)a 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 0 Well Alteration/Modification ■Other one(1)cone penetrometer test soundings <br /> ❑ Monitoring Well(s) #of wells D Soil Boring(s) #of borings E Geotechnical one(1) #of borings <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair pq <br /> 0 New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well Casing ^f <br /> WELL CONSTRUCTION C` T <br /> Drilling Method ■Mud Rotary 0 Air Rotary ■Auger ❑ Cable Tool ❑ Push Point ❑ Other D <br /> Proposed Well Depth 40 to 50 ft Excavation 2 to 8 in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size j dfa eter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft $qN J < ?O <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic [I Stainless Steel ❑ Qthgr OA <br /> Grout Seal Depth 40 to 50 ft ■Neat Cement(94 Ib bag15-10 gal water) ❑ Sand Cement "k,* <br /> T <br /> ❑ Bentonite(20%solids) ■Other up to 5%bentonite SPA p,TA }' <br /> Grout Placement Method ■Pumped 0 Free Fall ■Other Tremie Full-Depth 0 Retardant/Accelerator(name) T <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick <br /> in ❑ 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 �— Date S s-o? Area S I-vck4_>1 Employee ID# Ms <br /> Grout Inspection By Date :1 SPECIAL Well Permit <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well/Depth ft <br /> COMMENTS ONS- b0T_isrLf r _QiJ -7,T C4 A.) ZDZZ` <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Servic R uest# Invoice# Well ID# <br /> 7� 0 \ <br /> EHDO43-06 04/07/2022 /, ',/�� Page 1 of 2 Well/Pump Permit <br />