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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />rvUN-KEFUNDAHLE rERMIT <br />UALL (LUV) `JOS-/bUf FOR INSPECTIONS <br />hAPIKtb 9 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />)O,, o or, <br />2 I <br />/• i /l� � <br />e '7 �n L i , )e, it In ST CITY/ZIP <br />Stockton, CA <br />CROSS STREET <br />S Union St <br />ApN 16/90_2004 PARCEL SIZE <br />LAND USE APPLICATION If <br />OWNER NAME <br />pQ <br />V <br />L <br />Lee ` <br />PHONE <br />V J <br />PezzI �f�G k��n <br />OWNER ADDRESS <br />-69$7 <br />CITY/STATE/ZIP <br />CONTRACTOR <br />Kleinfelder <br />PHONE 661-302-2054 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 <br />SUBCONTRACTOR Taber Drilling <br />SUBCONTRACTOR ADDRESS 536 Galveston St <br />CITY/STATE/ZIP Stockton, CA 95206 <br />PHONE 916-371-8234 <br />CrrY/STATE/ZIP West Sacramento, CA 95691 <br />LICENSE C-57 -i C-61 -i D-09 fl Other NUMBER 969927 EXPIRATION DATE 2/28 <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) D Arsenic (4393) <br />INTENDED USE n Domestic/Private -1 Irrigation/Agricultural i Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />C] Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well L Replacement Well a Well Alteration/Modification /Other CPT <br />❑ Monitoring Well(s) # of wells / Soil Boring(s) 1 # of borings /Geotechnical 1 CPT # of borings <br />Out -Of -Service Well ❑ Out -Of -Service Well Renewal - Crass -Connection Repair <br />New PUMP U Pump Ke lacement LJ rump Ke air L Kaise well uasm <br />WELL CONSTRUCTION <br />Drilling Method /Mud Rotary F- Air Rotary /Auger n Cable Tool r Push Point / Other Direct Push <br />Proposed Well Depth 130 (max) It Excavation 8 (max) in diameter -1 Open Bottom F Gravel Pack/Gravel Size in diameter <br />Ll Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched -, Steel E Plastic C Stainless Steel -i Other <br />Grout Seal Depth 130 ( max) ft Neat Cement (94 Ib bag15-10 gal water) C Sand Cement sack mlx17 gal water <br />n Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall XOther Tremie n Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller n Pump Contractor -1 Other <br />n Concrete Pedestal r-IDimensions: Width ft Length ft Thick <br />in a Christy Box a Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level k <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 />1IINI MU NI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />�y DEPARTMENT USE ONLY <br />Application Accepted By / Date <br />Grout Inspection By Date <br />Pump Inspection By ate <br />.-ze LL <br />Soil Boring Inspection By ' Date <br />COMMENTS <br />Area Employee ID1i <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received lq� <br />Constructed Well Depth ,A.. <br />EHDO43-06 10/25/2021 Page 1 ort Well / Pump Permit <br />��: lie "1 <br />T <br />VIVA <br />M1 <br />VA <br />[TA <br />EHDO43-06 10/25/2021 Page 1 ort Well / Pump Permit <br />��: lie "1 <br />T <br />VIVA <br />M1 <br />