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1 WELL/PUMP PERMIT 2 Borings: 1 X $456 and 1 X $152 = $608 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS O19.4l. Cb6af h r 37.92076601-121.319115- CITY/ZIP Stockton, CA, 95206 <br />CROSS STREET Army Ct/W Charter Way APN 16-]3,34-01 j0. PARCEL SIZE 1.70 au LAND USE APPLICATION # Unknown <br />OWNER NAME Amanda Thnmac � S 7OG 1 �r PHONE (Z(Zg) 937-'7.540 <br />OWNER ADDRESS 425 N. EI Dorado St. CITY/STATE/ZIP Stockton, CA 95202 <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 <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP <br />_ PHONE (209) 993-2269 <br />Stockton, CA 95206 <br />LICENSE ■ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1044456 EXPIRATION DATE 09/30/2022 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ 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 <br />❑ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />❑ Well Alteration/Modification ❑ Other <br />❑ Soil Boring(s) #of borings EGeotechnical two (2) #ofborings C <br />❑ Out -Of -Service Well Renewal ❑ Cross-Connec Ioneair <br />11PumD ReDair ❑ Raise Well Casino p JvN o V �O <br />FN <br />Drilling Method ■ Mud Rotary ❑ Air Rotary ■ Auger ❑ Cable Tool ❑ Push Point ❑ Other h 41 Q U <br />Proposed Well Depth 70 to 100 ft Excavation 2 to 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size MiI bo' <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel C1Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 70 to 100 ft ■ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <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 />Application Accepted By = L� <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring I <br />COMMENTS IA <br />DEPARTMENT USE ONLY <br />Date 6 a r% <br />Date <br />Date <br />Date <br />11 <br />1 11 nn <br />Area ' sTat �T�%t Employee ID# // / <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Well Depth <br />ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Date Permit/ Invoice# WellID# <br />Remitted Service Request # <br />y37o' <br />1§0 <br />e <br />EHDO43-06 04/07/2022 CW Page] of 2 Well / Pump Permit <br />