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1 WELL/PUMP PERMIT SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSy A700 Il11pS�F►I��vr �t20�88°,-1415•° CITY/ZIP Stockton, CA, 95206 m Na Dr/Forrestal Village 14-503-011 52.52 au Unknown r CROSS STREET VY g APN PARCEL SIZE LAND USE APPLICATION# o A OWNER NAME Melanie Rodriguez contact persona Gloria Ruiz PHONE (209) 946-0246 ext 8281 OWNER ADDRESS 2201 W. Washington St CITY/STATE/ZIP Stockton, CA 95219 CONTRACTOR Gregg Drilling, LLC PHONE (925)313-5800 CONTRACTOR ADDRESS 950 Howe Road CITYISTATE21P Martinez, CA 94553 SUBCONTRACTOR Kleinfelder, Inc PHONE (209)993-2269 SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 LICENSE 0 C-57 C C-61 ❑ D-09 C Other NUMBER 1044456 ExPIRATION DATE 09x30/2022 DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391)! Dibromochloropropane(4392)I Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural C Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization LI Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ■Other one(1)cone penetrometer test soundings ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings E Geotechnical ane(1) #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal -1 Cross-Connection Repair pq C New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing ^I WELL CONSTRUCTION Drilling Method ■Mud Rotary C Air Rotary ■Auger C Cable Tool C Push Point C Other C Proposed Well Depth 40 to 50 ft Excavation 2 to 8 in diameter ❑ Open Bottom E Gravel Pack/Gravel Size )fi dtmeter L Conductor Casing in diameter / Conductor Casing Depth ft SA IV C ?0 Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel C Oth1-r ,IOA Grout Seal Depth 40 to 50 ft ■Neat Cement(94 Ib ba915-10 gal water) ❑ Sand CementNF T C Bentonite(20%solids) 00ther up to 5%bentonite "cr4 Q,Tq Y Grout Placement Method ■Pumped ❑ Free Fall ■Other Tremie Full-Depth ❑ Retardant/Accelerator(name) T PEDESTAL Installed By I Driller C Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick �in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑Turbine C 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. NW,INll NI 24 IfI)t R \D%'N%( F No -]I(F.RI'.Ql IRLD FOR INSPE("IIoNs-PLF v l ( N1 I t2419)953-761)? DEPARTMENT USE ONLY rL. Application Accepted By e� Date S �a Area 1 S tDJ4.0)4 Employee ID# rr/S Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date G1 ,y D WAIVER Received Soil Boring Inspection By Date l� l 1/1� Constructed Well Depth ft COMMENTS �- cQ- Q lJ Z7 T(4/L)E ZOZ.Z. PE SC Received Check#/ Amount Date PermlU Invoice# Well ID# Codes Info 8 Cash Remitted Sery c uest# q3Wp b EHIx013-06(/07202? /, , /�� Page I of 2 Well/Punr Permit