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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 1 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS =I cicC y -<,r . CITY/ZIP Stockton, CA <br />CROSS STREET E Clay St APN 15134022 <br />PARCEL SIZE LAND USE APPLICATION # <br />DWNER NAME UPRR PHONE <br />DWNER ADDRESS 844 E 5th St igDD Dou< 6rs S7 ftp X"10 CITY/STATE/ZIP Stockton <br />CONTRACTOR Kleinfelder <br />CA 95206 <br />PHONE 661-302-2054 <br />CONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 <br />SUBCONTRACTOR Taber Drilling PHONE 916-371-8234 <br />SUBCONTRACTOR ADDRESS 536 Galveston St CITY/STATE/ZIP West Sacramento, CA 95691 <br />LICENSE /C-57 -1 C-61 � D-09 rl Other NUMBER 969927 EXPIRATIONDATE 2/28/202�y <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private -1 Irrigation/Agricultural F Industrial Water Quality Monitoring Soil Sampling/Characterization <br />L Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK L New Well L Replacement Well a Well Alteration/Modification Other CPT <br />L Monitoring Well(s) # of wells /Soil Boring(s) 1 # /borings Geotechnical 1 CPT # of borings <br />L Out -Of -Service Well ❑ Out -Of -Service Well Renewal C Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method /Mud Rotary L Air Rotary XAuger n Cable Tool F- Push Point / Other Direct Push <br />Proposed Well Depth 150 (max) ft Excavation 8 (max) in diameter -1 Open Bottom F Gravel Pack/Gravel Size in diameter <br />Li Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad 7 Steel L Plastic G Stainless Steel 7 Other <br />Grout Seal Depth 150 (max) It ,/ Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack m/x/7 gal water <br />F1 Bentonite (20% solids) P Other <br />Grout Placement Method Pumped Free Fall Other Tremie ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller n Pump Contractor -1 Other <br />n Concrete Pedestal nDimensions: Width ft Length It Thick <br />n L Christy Box L Stove Pipe <br />PUMP L 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 PA s — <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 3 ;t1 a2 <br />Grout Inspection By Date <br />Pump Inspection By r <br />Soil Boring Inspection By ate c7 2 ZZ <br />COMMENTS <br />Area I 4,3C k43)4 Employee ID: <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received SAN <br />Constructed Well Depth �r�Y! <br />L «i7ff/Iii.:1�1G�S�iE <br />Zf <br />EHDO43-06 10/292021 Pae 1 0 2 Well /Pump Permit <br />p�--3c.P <br />98»� <br />