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Y � f WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LION AVENUE - STOCKTON CA 95205-6232 (209)468-3420 NUN-KEFUNDABLE PERMIT wwvv.S ov.or Jeno tAF'IKtb 1 YEAR FROM UATE ISSUED /lyl JOB ADDRESS C ¢ jt%s' eFS 38.021040°. Log: -121.363676° clrv/zlP Stockton. CA, 95206 CROSSSTREET Mariners Dr/Hammer Ln APN 071-260-100 PARCELSME 10.6 LAND USE APPLICATION# Unknown OWNER NAME RPM Company/Brenda Liahtle _Sar MorIl19f,S Aw$HONE (209) 609-5709 OWNER ADDRESS 1420 S Mills Avenue, Suite M CITYISTATE/ZIP Lodi, CA 95242 CONTRACTOR Gregg Drilling, LLC PHONE (925) 313-5800 CONTRACTOR ADDRESS 950 Howe Road CITY/STATEIzIP Martinez, CA 94553 SUBCONTRACTOR/CONSULTANT Kleinfelder, Inc PHONE (209) 993-2269 SUBCONTRACTOR/CONSULTANT ADDRESS 2001 Arch Airport Rd, Suite 100 CITY/STATE/ZIP Stockton, CA 95206 LICENSE N C-57 D C-61 G D-09 ❑ Other NUMBER 1044456 EXPIRATION DATE 09/30/2022 BILLING PARTY: C OWNER ❑ CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) ❑ Arsenic (4393) INTENDED USE ❑ Domestic/Pdvate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization ❑ Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings E Geotechnical one (1) # of borings ❑ Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary - Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 45 It Excavation 8 in diameter ❑ Open Bottom - Gravel Pack/Gravel Size in diameter 11 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic D Stainless Steel ❑ Other Grout Seal Depth 45 It E Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixf7 gal water ❑ Bentonite (20% solids) E Other up to 5% bentonite Grout Placement Method 0 Pumped ❑ Free Fall N Other Tremie Full -Depth n Retardant / Accelerator (name) PEDESTAL Installed By n Driller ❑ Pump Contractor Other D Concrete Pedestal ❑Dimensions: Width ft Length it Thick in D Christy Box ❑ Stove Pipe PUMP D Submersible❑ Turbine D Other HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND AC71VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN/l/�llLl/-M , R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED /IAHLV A� TITLE Operations Manager DATE 11/30/2021 SEE ATTACHED BORING LOCATION MAP DEPARTMENT USE NLY Application Accepted By L Date t a.a7 Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS Area? Stb4k40 Employee ID#/`A ❑ SPECIAL Well Permit 7I WAIVER Received Constructed Well Depth ft y D 0 A REcF � �V�O EC 8 ?0 R p U/N C ?% ��FpgR ��Y PE Codes SC Received Check#/ Info Cash Amount D to Permit/ Invoice # Well ID# Remitted Service Re uest# 4 I I'so j ,�b EHD43-06 6111/2019 �W./��/Q? WELL/PUMP PERMIT