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1 6 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT (:ALL ZUy y53 -/117y/ FOR INSPECTIONS LAVIKLb 7 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3 (7%► �* i �P : 37.9207660,-121.3191150 CITY/ZIP Stockton, CA, 95206 <br />CROSS STREET Turnpike Rd/West Side FwyAPN 16-528-054 PARCEL SIZE 1.70 acr LAND USE APPLICATION # Unknown <br />OWNER NAME SAFStor Turnpike, LLC (Andrew Young) PHONE <br />OWNER ADDRESS 444 Seabreeze Blvd. CITY/STATE/ZIP Daytona Beach, FL 32118 <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 <br />SUBCONTRACTOR ADDRESS <br />2001 Arch Airport Rd, Suite 100 <br />LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ <br />CITY/STATE/ZIP <br />_ PHONE (209) 993-2269 <br />Stockton, CA 95206 <br />NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br />DOMEsnc WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) a Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring N 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 <br />Sc Received Check#/ <br />Info B Ca h <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) # of borings E Geotechnical three (3) # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />I Ir <br />ECF/ <br />Drilling Method ■ Mud Rotary ❑ Air Rotary ■ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 30 to 60 ft Excavation 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size. diamete <br />11 Conductor Casing in diameter / Conductor Casing Depth ft <br />C <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel <br />❑ Ott J <br />Grout Seal Depth 30 to 60 ft ■ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement <br />_17S" �X�I)anfate <br />❑ Bentonite (20% solids) ■Other up to 5% bentonite <br />�gLTN 0NM�e <br />Grout Placement Method ■ Pumped ❑ Free Fall ■ Other Tremie Full -Depth ❑ Retardant / Accelerator (name) <br />AR r. <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ 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 />NI HNIMUNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By �L — Date 711 ri b <br />Grout Inspection By Date <br />Pump Inspection By 4 A Date <br />Soil Boring Inspection By d Date <br />COMMENTS <br />Areai S �J4" y;mployee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />TZ <br />m <br />g <br />0 <br />A <br />M <br />to <br />PE <br />Codes <br />Sc Received Check#/ <br />Info B Ca h <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted I t Service Re uest # <br />EHDO43-06 04/07/2022Page I of 2 �� ��,_,`Z'LA!> Zt Wel I / Pump Permit <br />�T <br />