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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209)498-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS f0Pu 1.. • ("""y '-•}, CITY2IP aockton, CA <br />CROSS STREET E Charter W APN 15136002 PARCEL SIZE I • LAND USE APPLICATION 7 <br />NAME UPRR <br />PHONE <br />ADDRESS 844 E 51th St Igoo DOL �: �-t �h� 9> I �1J CITY/STATE/ZIP Stock Lun, CA 9520E orr':Ale <br />Kleinfelder <br />ADDRESS 2001 Arch Airport Rd, Suite 100 <br />Taber Drilling <br />ADDRESS 536 Galveston St <br />PHONE 661-302-205-i <br />CITY/STATE/71P Stockton, CA 95206 <br />PHONE 916-371-8234 <br />CITY/STATE/ZIP Nest Sacramento, CA 95691 <br />C-57 C-61 i D-09 r Other NUMBER 969921 EXPIRATION DATE 2/28/202 4 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />H different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />New Well Replacement Well I Well AlterationlModificationOther CPT <br />Monitoring Well(s) # of wells Soil Boring(s) 1 # bonngs Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal I Cross -Connection Repair <br />1 CPT #ofboringa <br />Drilling Method //Mud Rotary Air Rotary Auger Cable Tool Push Point / Other Direct Push <br />Proposed Well Depth 150 (max) ft Excavation a (max) in diameter Open Bottom Gravel Pack/Gravel Size in diamete <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel 7 Other <br />Grout Seal Depth 150 (max) It % Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal wate <br />Bentonite (20% solids) Other <br />Grout Placement Method / Pumoed i Free Fall XOther Tremie Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor IOther <br />Concrete Pedestal Dimensions. Width ft Length ft Thick <br />�in Christy Box Stove Pipe <br />PUMP SUbmersibleD Turbine I 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 />1 / DEPARTMENT USE ONLY <br />Application Accepted By L @(e*SIOU'Rit- <br />1 <br />Grout Inspection Bylffto— <br />Pump Inspection By Dale <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area_ / .k J)^ Employee ID# <br />❑ SPECIAL Well Permit Reci <br />❑ WAIVER Received �,/ <br />Constructed Weil Depth ' r 7 <br />A <br />m <br />N <br />16h)71`7 <br />'Eiyr <br />veo <br />202; <br />EHD04i. 10,25 2021 Pp I aft <br />can Pwnr p—," <br />SIV py <br />kL <br />ENT <br />