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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 />NON-REFUNDABLE PERMIT GALL (209) 953-1b97 FOR INSPECTIONS LXIJIKt1 7 TEAR FROM DATE ISSUED <br />JOB ADDRESS 0 ode)) i Levee: 37.914338', -121.2)8j0864' CITY/zIP Stockton, CA, 95206 <br />CROSS STREET Odell Avenue APN /leer 17,Su 016 PARCEL SIZE NSA LAND USE APPLICATION # Unknown <br />OWNER NAME City of Stockton Public Right of Way PHONE (209) 937-8561 <br />OWNER ADDRESS 345 N. EI Dorado Street <br />CONTRACTOR Gregg Drilling, LLC <br />CONTRACTOR ADDRESS 950 Howe Road <br />SUBCONTRACTOR Kleinfelder, Inc <br />SUBCONTRACTOR ADDRESS 2001 Arch Airport Rd. Suite 100 <br />LICENSE ■ C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />CITY/STATE/ZIP Stockton, CA 95202 <br />PHONE (925)313-5800 <br />CITY/STATE/ZIP Martinez, CA 94553 <br />PHONE (209) 993-2269 <br />CITY/STATE/ZIP Stockton, CA 95206 <br />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 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 <br />❑ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />❑ New Pump ❑ PumD ReDlacement <br />❑ Well Alteration/Modification ❑ Other <br />❑ Soil Boring(s) # of borings N Geotechnical two (2) # of <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ Pump Repair ❑ Raise Well Casing <br />ring CC� Nr <br />41v <br />WELL CONSTRUCTION Qq /V V <br />Drilling Method ■ Mud Rotary ❑ Air Rotary ■ Auger ❑ Cable Tool ❑ Push Point ❑ Other FN 'Jo <br />Q <br />Proposed Well Depth 50 ft Excavation 4 to 8 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size TNA <br />L1 Conductor Casing in diameter / Conductor Casing Depth ft pgRT�� <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 50 ft ■Neat Cement (94 Ib bag15-10 gal water) ❑ Sand Cement sack mix/7 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 />DEPARTMENT USE ONLY <br />Application Accepted By —/rte Da. °�3 , �R ;z <br />Grout Inspection By Date <br />Pump Inspection By Date qq <br />Soil Boring t �In ion ion B Date <br />COMMENTS[��! <br />Area I 044'k, Employee ID# A C <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received Check#/ <br />Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />7 <br />I�� <br />d <br />EHDO43-06 04/07t2022 (� Page I of 2 Well /Pump Permit <br />1"6+ 7�1 l `877 9 2� <br />rr <br />T <br />