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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1863 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL ZUy 553-/69/ FOR INSPECTIONS LXPIKLS 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS r ga d 0 G S4IyI j+r'i'1 3"1`9i'A�`88'°, "TZt'�t9#-�-6� CITv/ZIP Stockton, CA, 95206 <br />CROSS STREET Navy Dr/W Washington St APN 14-502-013 PARCEL SIZE 3.46 ar-I'LANDUSE APPLICATION## Unknown <br />OWNER NAME Melan'ei•• quez contactperson: Gloria• 19 946-0246 <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 CITY/STATE/ZIP Martinez, CA 94553 <br />SUBCONTRACTOR Kleinfelder, Inc PHONE (209) 993-2269 <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 <br />LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring E 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 E Other one (1) cone penetrometer test soundings <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings E Geotechnical one (1) # of borings <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing I/"A <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1 ❑ Push Point ❑ Other <br />Proposed Well Depth 40 to 100 ft Excavation 2 to 8 in diameter ❑ Open Bottom 0 Gravel Pack/Gravel Size in di7aiNvIlU <br />❑ Conductor Casing in diameter / Conductor Casing Depth it S 6 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel l <br />Grout Seal Depth 40 to 100 ft ■ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement NEq� //s�� �ihl6rfi,Qel water <br />❑ Bentonite (20% solids) ■Other up to 5% bentonite DF M�%)VUNik <br />Grout Placement Method ■ Pumped ❑ Free Fall ■ Other Tremie Full -Depth ❑ Retardant / Accelerator (name) IN W191 <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal 0Dimensions: 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 G� l� Date <br />Grout Inspection By <br />Pump Inspection By J <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Date—q 3 <br />Area 1 s 01kt11>7 Employee ID# mS <br />7 SPECIAL Well Permit <br />7 WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info B C h <br />Amount Permit/ <br />Remitted Date Service Request # Invoice # Well ID# <br />7a <br />150 <br />408 22Lon 3140 <br />EHDO43-0604/07/2022 mac. /1/' /� / Page I of2 <br />! <br />Wel I /Pump Permit <br />