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f � , <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL (ZUtI) yQ3-/bUt FOR INSPECTIONS LAVIKC, 7 TEAR FROM UATE ISSUED <br />.JOB ADDRESS U �'�, CITY/ZIP Stockton, CA, 95206 <br />CROSS STREET Navy Dr/W Washington St APN 14-502-018 PARCEL SIZE95.50 aCLAND USE APPLICATION # Unknown <br />OWNER NAME Melanie Rodriguez contact person: Gloria Ruiz PHONE (209) 946-0246 ext 8281 <br />OWNER ADDRESS 2201 W. Washington St CITY/STATE/ZIP Stockton, CA 95219 <br />CONTRACTOR Gregg Drilling, LLC PHONE (925) 313-5800 <br />CONTRACTOR ADDRESS 950 Howe Road <br />SUBCONTRACTOR Kleinfelder, Inc <br />CITY/STATE/ZIP Martinez, CA 94553 <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP <br />LICENSE N 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) u Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 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 E Geotechnical two (2) # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair It. <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing A^1 ym <br />WELL CONSTRUCTION . 1, <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 40 to 60 ft Excavation 2 to 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size tylqy <br />?,r�tet <br />11 Conductor Casing in diameter / Conductor Casing Depth ft S4 /y '10 <br />J <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel LlQtb� q Q <br />Grout Seal Depth 40 to 60 ft ■ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement si�eRp� <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 />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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By C� L L-- Date <br />Grout Inspection By Date <br />Pump Inspection By 4 Date <br />Soil Boring Inspection By " Date* I <br />COMMENTS <br />Area IM04 0 Employee ID# In -5 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />N <br />m <br />g <br />O <br />N <br />C7 <br />9 <br />rT <br />D <br />Gly <br />T <br />PE SC Received Check#/ <br />Codes Info B Ca h <br />Amount Date <br />Remitted I i <br />Permit/ Invoice # Well ID# <br />Service Request # <br />437,2 <br />14 - <br />EHD043-06 OS/07/2022W/ ifl / YL , / �� P 1 of 2 Wel I /Pump Permit <br />