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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 />NUN -REFUNDABLE PERMIT CALL <br />953-7697 FOR INSPECTIONS <br />JOB ADDRESS olII1 L-h,(Artff :37.920766°,-121.319115° <br />CROSS STREET Navy Dr/Forrestal Village APN 16-334-j0�09 F <br />OWNER NAME Amanda Thomas /Glt i1 6i" S�OLK0), <br />OWNER ADDRESS 9099 Mariners Drive <br />CONTRACTOR Gregg Drilling, LLC <br />CONTRACTOR ADDRESS 950 Howe Road <br />SUBCONTRACTOR Kleinfelder, Inc <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP Stockton, CA, 95206 <br />SIZE 27.56 acLAND USE APPLICATION # Unknown <br />PHONE 09)937-7540 <br />CITY/STATE/ZIP Stockton. CA 95219 <br />PHONE (925) 313-5800 <br />CITY/STATE/ZIP Martinez, CA 94553 <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP <br />LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1044456 <br />_ PHONE (209) 993-2269 <br />Stockton, CA 95206 <br />EXPIRATION DATE 09/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 1_ 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 One (1) cone penetrometer test soundings <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings N Geotechnical 1 <br /># of borinop; <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing`�.pit <br />WELL CONSTRUCTION <br />116 <br />4116.? <br />Drilling Method ■ Mud Rotary ❑ Air Rotary ■ Auger ❑ Cable Tool ❑ Push Point Other <br />41 <br />Proposed Well Depth 70 to 100 ft Excavation 2 to 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizeM in diame <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Fi Q(1//V <br />FNM Co <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched [ISteel ❑ Plastic ❑ Stainless Steel <br />❑ Other�TN / <br />Grout Seal Depth 70 to 100 ft ■ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 <br />❑ Bentonite (20% solids) ■Other up to 5% bentonite <br />Grout Placement Method ■ Pumped ❑ Free Fall ■ Other Tremie Full -Depth ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />n ❑ 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date e 3/ v7-2 Area S 1� ��� Employee ID# S <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By _ Date �f El WAIVER Received <br />Soil Boring Inspection By ate 0 �,2 4 Constructed Well Depth ft <br />COMMENTS 061tc.{rr encrouchr�+eY►� perr��f's �� OtHer perm�ls r F rPQ�,,ieG/ <br />T <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Dat Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />437a sa <br />6;q <br />EHDO43-06 04/07/2022�1�/DiOL-f-76 Page I of i Well / Pump Permit <br />